Treatment preference in hypochondriasis

Efficacy of internet-based psychological interventions for pathological health anxiety: A three-level meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to provide a comprehensive summary and synthesis of available evidence on the efficacy of internet-based psychological interventions for pathological health anxiety, as well as to examine the variables that possibly moderate intervention effects.

METHOD

Four databases were searched for the literature up to October 2023. A three-level random-effects model was used to estimate the pooled effect size, with Hedge's g as the measure.

RESULTS

We extracted 28 effect sizes from nine eligible randomized controlled trials with 1079 participants. The results showed that internet-based psychological interventions had a moderate to large between-group effect on health anxiety (g = 0.70) that was significant both at post-intervention (g = 0.74) and follow-up (g = 0.64). Furthermore, these interventions were significantly more effective than passive control conditions including waitlist, usual care, and placebo at post-treatment (g = 1.07), but had effects comparable to active control groups at both post-intervention and follow-up.

CONCLUSIONS

Internet-based psychological interventions are an effective way to alleviate pathological health anxiety. We recommend that these interventions be more widely implemented in routine care settings to ensure easy accessibility for patients with health anxiety.

Do You Mind? Examining the Impact of Psychoeducation Specificity on Perceptions of Mindfulness-Based Programs

Objective: Mindfulness-based programs (MBPs) cultivate the capacity for mindfulness, defined as nonjudgmental acceptance and awareness of present-moment experience. Mindfulness has been associated with a host of benefits for users, such as improved indices of mental well-being. We examined public perceptions of acceptability (i.e., how appropriate the treatment is for a given problem) and credibility (i.e., how logical and convincing a treatment seems) of MBPs as a form of mental health intervention. The main objective of this study was to examine whether higher specificity of psychoeducational content improved perceptions of the acceptability and credibility of MBPs. Methods: Participants (n = 188; female% = 39.4) were recruited online and randomly assigned to one of two conditions. In one condition, participants received balanced and evidence-based psychoeducation specific to MBPs for mental health. In the other condition, participants received general information about psychological treatments for mental health. Acceptability and credibility perceptions were measured by questionnaires across time (pre-and post-psychoeducation) and across specificity conditions (specific vs. general psychoeducation). Results: Participants randomized to the general, but not the specific, psychoeducation-endorsed higher scores of acceptability of MBPs post-psychoeducation. Further, participants endorsed higher scores of MBP credibility post-psychoeducation, regardless of the specificity of psychoeducation provided. Conclusions: Perceptions of the acceptability of MBPs were improved following exposure to general psychoeducation, and perceptions of the credibility of MBPs were improved following psychoeducation, regardless of specificity. Examining public perceptions of MBPs is important for informing strategies to support access to and use of MBPs.

Evaluation of a decision aid for the treatment of depression among college students

Objective: Depression, and its treatment, is a concern among college students. Research indicates decision aids (DA) improve patients' treatment knowledge, decision making, and decisional conflict; however, it is unknown whether they are helpful for disseminating depression treatment information to college students. This study evaluated a DA for depression and its impact on college students' knowledge and treatment decision making. Methods: College students (N = 144) completed questionnaires pre-, post-, and at 1-month follow-up after reviewing an evidence-based DA for depression. Results: Participants rated the DA as highly acceptable and useful, and their knowledge increased at post-treatment and follow-up. However, treatment option presentation order influenced decision making. Conclusions: This DA is a useful and acceptable decision-making tool, and increased knowledge of depression and its treatment among college students. This study proposes a novel tool for educating college students about depression treatment, furthering our understanding of factors influencing treatment preferences.

Barriers and facilitators to implementing interventions for medically unexplained symptoms in primary and secondary care: A systematic review

OBJECTIVE

To integrate existing literature on barriers and facilitators to implementing interventions for Medically Unexplained Symptoms (MUS) in primary and secondary care.

METHOD

Systematic review following PRISMA guidelines. A search of PsychINFO/Pubmed/Web of Science was performed to select studies focusing on MUS-interventions and implementation. All included papers were checked for quality and bias. A narrative synthesis approach was used to describe the included papers by implementation level, ranging from the specific intervention to the broader economic/political context.

RESULTS

20 (quantitative/qualitative/mixed design) papers were included, but the quantitative studies especially, lacked methodological quality, with possible publication bias as a result. Results showed that the intervention needs to be acceptable and in line with daily practice routines. The professional's attitude and skills are important for implementation success, as well as for overcoming problems in the professional-patient interaction. If patients stick to finding a somatic cause, this hampers implementation. A lack of time is a frequently mentioned barrier at the organizational level. Barriers/facilitators at the social context level and at the economic/political level were barely reported on in the included papers.

CONCLUSION

Results were integrated into an existing implementation model, as an example of how MUS-interventions can be successfully implemented in practice.

Cyberchondria: conceptual relation with health anxiety, assessment, management and prevention

There is a need to synthesize available information on the emerging construct of cyberchondria to guide evidence informed practice. With this in mind, electronic search of databases including MEDLINE via PubMed, Cochrane Library, ScienceDirect and Google scholar were carried out from inception till March 2020 to identify relevant English language peer reviewed articles related to cyberchondria. Generated abstracts were grouped according to their thematic focus and summarized. A total of 49 articles were reviewed. Articles directly evaluating cyberchondria were very few and most of the treatment evidence was extrapolated from trials on health anxiety. Cyberchondria appears to be a phenomenologically overlapping entity with, yet distinguishable from, health anxiety and there may be merit in studying the two constructs separately. Four validated self-assessment measures for cyberchondria are available in literature. Cognitive behaviour therapy (CBT) delivered either physically or through the internet (iCBT) have been found to be effective for both health anxiety and cyberchondria. Pharmacologic strategies for health anxiety have mainly involved the use of Selective Serotonin Reuptake Inhibitors, with mean effective dosages higher than for depression/anxiety. Prevention of cyberchondria needs to focus on appropriate harm reduction strategies as well as supply and demand side measures. Internet based CBT therapies hold promise for management of cyberchondria. This finding must be considered preliminary due to limited evidence. Further study is required to establish the diagnostic validity of cyberchondria.

The mediating effect of health anxiety in the relationship between functional somatic symptoms and illness behavior in Chinese inpatients with depression

BACKGROUND

Functional somatic symptoms in depression disorder may cause inappropriate illness behavior hindering the treatment process. Health anxiety may play a role in this relationship, but few studies have examined it. The current study aimed to investigate the role of health anxiety in the relationship between functional somatic symptoms and illness behavior in patients with depression.

METHODS

The present study recruited 323 hospitalized patients with depression to complete the Patient Health Questionnaire-15, Whiteley-Index-7, and Scale for the Assessment of Illness Behavior, then constructed a structural equation model to examine whether health anxiety mediated the relationship between functional somatic symptoms and illness behavior.

RESULTS

The results showed significant correlations between any two of the three variables of interest. More importantly, health anxiety played a partially mediating role (42.86%) in the relationship between functional somatic symptoms and illness behavior. Further analysis suggested that elderly patients reached higher health anxiety than younger patients when their functional somatic symptoms were mild.

CONCLUSIONS

These results highlight that health anxiety may mediate the influence of functional somatic symptoms on illness behavior. The implications of assessing and intervening in health anxiety in patients with depression were discussed.

Severe Illness Anxiety Treated by Integrating Inpatient Psychotherapy With Medical Care and Minimizing Reassurance

Illness anxiety disorder (IAD, formerly hypochondriasis) is characterized by preoccupation with fear of serious illness despite medical reassurance. IAD is common, debilitating, challenging to treat, and results in high healthcare utilization. Outpatient management of IAD is challenging because patients can compulsively seek reassurance from numerous providers, which interferes with learning more productive coping skills. We present the case of a woman with severe IAD who presented to the emergency room with increasing frequency over several months, despite regular outpatient medical visits and escalating psychiatric care. We made the unusual decision to hospitalize her for IAD for 1 month, in the absence of typical hospitalization criteria. This hospitalization allowed us to consolidate all medical and psychiatric care into a single provider team and train all staff and family to communicate with her in a consistent manner. We successfully treated her by integrating a general cognitive-behavioral therapy (CBT) protocol into medical care and decision-making. In response to her numerous health concerns, we minimized medical work-up, reassurance, and reactive medication changes, and instead used the concerns as opportunities to reinforce the psychotherapy. This approach allowed us to simplify her medication regimen and manage her co-morbid hypertension and vitamin deficiencies. Though inpatient hospitalization is likely infeasible in most cases of IAD, outpatient providers may create similar treatment plans based on the example of our case report, without needing highly specialized expertise. Such a plan would require a straightforward understanding of IAD psychology, which we review here, combined with readily accessible tools including a universal CBT protocol, online CBT courses, and clinical symptom scales. We discuss our approach for responding to health concerns, maintaining therapeutic alliance, integrating CBT principles into patient interactions, and managing medications. Since patients with IAD share health concerns with all providers, staff, and family, we also include our own IAD communication guide, appropriate for a general audience, that demonstrates how to respond in these conversations.

Recent Advances in the Understanding and Treatment of Health Anxiety

PURPOSE OF REVIEW

To examine the diagnosis of health anxiety, its prevalence in different settings, public health significance, treatment, and outcome.

RECENT FINDINGS

Health anxiety is similar to hypochondriasis but is characterized by fear of, rather than conviction of, illness. Lifetime prevalence rates are 6% in the population and as high as 20% in hospital out-patients, leading to greater costs to health services through unnecessary medical contacts. Its prevalence may be increasing because of excessive internet browsing (cyberchondria). Drug treatment with antidepressants has some efficacy but is not well-liked, but psychological treatments, including cognitive behavior therapy, stress management, mindfulness training, and acceptance and commitment therapy, given either individually, in groups, or over the Internet, have all proved efficacious in both the short and longer term. Untreated health anxiety leads to premature mortality. Health anxiety has become an increasing clinical and public health issue at a time when people are being formally asked to take more responsibility in monitoring their own health. More attention by health services is needed.

Health anxiety: detection and treatment

Health anxiety is an important new diagnosis that is increasing in frequency because of changing attitudes towards health, particularly excessive use of health information on the internet (cyberchondria). People with abnormal health anxiety become over-diligent monitors of their health, misinterpret most somatic sensations as evidence of disease, consult medical professionals unnecessarily and frequently, and are often over-investigated. Relatively few patients with health anxiety present to psychiatrists; most are seen in primary and secondary medical care. This paper reviews the diagnosis and presenting features of health anxiety, its identification in practice and its treatment. A range of simple psychological treatments have been shown to have long-lasting benefit for the disorder but are greatly under-used.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients

BACKGROUND & OBJECTIVES

While cognitive behaviour therapy (CBT) is an established treatment for health anxiety, there are barriers to service access. Internet-delivered cognitive behaviour therapy (ICBT) has demonstrated effectiveness and has the potential to improve access to treatment. Nevertheless, it is unknown how patients perceive ICBT relative to other interventions for health anxiety and what factors predict ICBT acceptability. This study investigated these questions.

METHODS

Primary care patients (N = 116) who reported elevated levels of health anxiety were presented three treatment vignettes that each described a different protocol for health anxiety (i.e., medication, CBT, ICBT). Acceptability and credibility of the treatments were assessed following the presentation of each vignette. Participants then ranked the three treatments and provided a rational for their preferences.

RESULTS

The treatments were similarly rated as moderately acceptable. Relative to medication and ICBT, CBT was perceived as the most credible treatment for health anxiety. The highest preference ranks were for CBT and medication. Regression analyses indicated that lower computer anxiety, past medication use, and lower ratings of negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability.

LIMITATIONS

Health anxiety was not assessed with a diagnostic interview. Primary care patients were recruited through a Qualtrics panel. Patients did not have direct experience with treatment but learned about treatment options through vignettes.

CONCLUSIONS

Medication and CBT are preferred over ICBT. If ICBT is to increase treatment access, methods of improving perceptions of this treatment option are needed.

Pilot trial of a therapist-supported internet-delivered cognitive behavioural therapy program for health anxiety

Cognitive behavioural therapy (CBT) is an effective treatment for health anxiety, but more research is needed to evaluate accessible, low cost ways of delivering CBT. Internet CBT may be effective, but there are no iCBT programs available outside of Sweden. We developed the first English-language clinician-guided iCBT program for health anxiety and conducted an open pilot trial (n = 16) to examine its acceptability, and impact on health anxiety and comorbidity, disability, and the cognitive and behavioural factors thought to maintain the disorder (e.g., catastrophising, hypervigilance). 13/16 participants completed the program (81% adherence). We found large and significant reductions in health anxiety, depression, distress, anxiety and disability (g's > 1.0), dysfunctional cognitions, behaviours and body vigilance between pre- and post-treatment, which were maintained at 3-month follow-up. The results provide preliminary support for the use of iCBT for health anxiety. Randomised controlled efficacy trials are now needed to evaluate this program.

Parents' Perceptions of Novel Treatments for Child and Adolescent Specific Phobia and Anxiety Disorders

This study aimed to examine parents' perceptions of established treatments, including cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), relative to novel treatments of D-cycloserine (DCS) and attention bias modification (ABM) augmented CBT to determine if novel treatments are perceived as more or less favorable than established treatments. Participants included parents of children with a specific phobia, enrolled in one of two randomized controlled trials of either one-session augmented DCS (n = 38, Gold Coast) or ABM augmented one-session treatment (n = 34, Brisbane), as well as parents from a community sample (n = 38). Parents of children with a specific phobia perceived CBT most favorably. There was no difference between the sites on perceptions of ABM. However, parents of children enrolled in the DCS trial perceived DCS more favorably than parents of children enrolled in the ABM trial and the community sample. These results demonstrate parents' greater acceptance of psychological treatments over pharmacological treatments for the treatment of childhood phobias, highlighting the importance of educating parents to novel treatments.

Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators

The present investigation employed meta-analysis to examine the efficacy of cognitive-behavioral therapy (CBT) for hypochondriasis/health anxiety as well as potential moderators that may be associated with outcome. A literature search revealed 15 comparisons among 13 randomized-controlled trials (RCTs) with a total sample size of 1081 participants that met inclusion criteria. Results indicated that CBT outperformed control conditions on primary outcome measures at post-treatment (Hedges's g = 0.95) and at follow-up (Hedges's g = 0.34). CBT also outperformed control conditions on measures of depression at post-treatment (Hedges's g = 0.64) and at follow-up (Hedges's g = 0.35). Moderator analyses revealed that higher pre-treatment severity of hypochondriasis/health anxiety was associated with greater effect sizes at follow-up visits and depression symptom severity was significantly associated with a lower in effect sizes at post-treatment. Although effect size did not vary as a function of blind assessment, smaller effect sizes were observed for CBT vs. treatment as usual control conditions than for CBT vs. waitlist control. A dose response relationship was also observed, such that a greater number of CBT sessions was associated with larger effect sizes at post-treatment. This review indicates that CBT is efficacious in the treatment of hypochondriasis/health anxiety and identifies potential moderators that are associated with outcome. The implications of these findings for further delineating prognostic and prescriptive indicators of CBT for hypochondriasis/health anxiety are discussed.

Strategies for managing symptoms of anxiety

The purpose of this article is to summarize strategies for effectively managing the symptoms of anxiety. The distinction between the cognitive, physiological and behavioral components of fear and anxiety is explained and various treatment targets are outlined. Empirically-supported strategies that are effective in alleviating common symptoms of anxiety are reviewed. These include various forms of psychosocial intervention (i.e., cognitive and behavioral therapies), pharmacotherapy, in addition combined treatment approaches. Expert consensus guidelines, prognostic factors, patient preferences and accessibility issues are discussed with regard to treatment selection in addition to emerging challenges in the field and future research directions.

Health anxiety disorders in older adults: conceptualizing complex conditions in late life

Health anxiety disorders (e.g., hypochondriasis) are prevalent but understudied in older adults. Existing research suggests that severe health anxiety has a late age of onset, perhaps because of comorbidity with physical health conditions that are more likely to occur with aging. Despite being under diagnosed in later life due to a lack of age-appropriate diagnostic criteria, significant positive associations with age suggest that health anxiety disorders are more prevalent in older than younger adults. Preliminary research also highlights the complexity of these disorders in older adults and the potential importance of medical morbidity as a risk factor. This review explores the complexities of health anxiety disorders in later life with a focus on understanding defining features, prevalence rates, correlates, assessment, diagnosis, and treatment. We offer a theoretical model of the development of severe health anxiety among older adults to encourage further research on this important and under-studied topic.

Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review

OBJECTIVE

Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders.

DATA SOURCES

A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search.

STUDY SELECTION

Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion.

DATA EXTRACTION

Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment.

RESULTS

The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples.

CONCLUSIONS

Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.

A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis)

Objective: The efficacy and acceptability of existing psychological interventions for health anxiety (hypochondriasis) are limited. In the current study, the authors aimed to assess the impact of mindfulness-based cognitive therapy (MBCT) on health anxiety by comparing the impact of MBCT in addition to usual services (unrestricted services) with unrestricted services (US) alone. Method: The 74 participants were randomized to either MBCT in addition to US (n = 36) or US alone (n = 38). Participants were assessed prior to intervention (MBCT or US), immediately following the intervention, and 1 year postintervention. In addition to independent assessments of diagnostic status, standardized self-report measures and assessor ratings of severity and distress associated with the diagnosis of hypochondriasis were used. Results: In the intention-to-treat (ITT) analysis (N = 74), MBCT participants had significantly lower health anxiety than US participants, both immediately following the intervention (Cohen's d = 0.48) and at 1-year follow-up (d = 0.48). The per-protocol (PP) analysis (n = 68) between groups effect size was d = 0.49 at postintervention and d = 0.62 at 1-year follow-up. Mediational analysis showed that change in mindfulness mediated the group changes in health anxiety symptoms. Significantly fewer participants allocated to MBCT than to US met criteria for the diagnosis of hypochondriasis, both immediately following the intervention period (ITT 50.0% vs. 78.9%; PP 47.1% vs. 78.4%) and at 1-year follow-up (ITT 36.1% vs. 76.3%; PP 28.1% vs. 75.0%). Conclusions: MBCT may be a useful addition to usual services for patients with health anxiety.

Health anxiety: current perspectives and future directions

Health anxiety is a ubiquitous experience that arises when bodily sensations or changes are believed to be indicative of a serious disease. Severe expressions of health anxiety are most often classified as hypochondriasis in the current DSM-IV-TR; however, various alternative classification schemas have been proposed for the DSM-V. Regardless of classification, severe health anxiety has significant negative impacts on well-being, social and occupational functioning, and health care resource utilization. In this review, we focus on classification issues pertinent to severe health anxiety, summarize recent research regarding potential mechanisms underlying the condition, and summarize the state of the art with respect to assessment and treatment. Future research directions are noted and suggested throughout.

Assessment of preferences for treatment: validation of a measure

Systematic measurement of treatment preferences is needed to obtain well-informed preferences. Guided by a conceptualization of treatment preferences, a measure was developed to assess treatment acceptability and preference. The purpose of this study was to evaluate the psychometric properties of the treatment acceptability and preferences (TAP) measure. The TAP measure contains a description of each treatment under evaluation, items to rate its acceptability, and questions about participants' preferred treatment option. The items measuring treatment acceptability were internally consistent (alpha > .80) and demonstrated validity, evidenced by a one-factor structure and differences in the scores between participants with preferences for particular interventions. The TAP measure has the potential for the assessment of acceptability and preferences for various behavioral interventions.

"I need to talk about it": a qualitative analysis of trauma-exposed women's reasons for treatment choice

A significant proportion of individuals suffering from posttraumatic stress disorder do not seek or receive effective treatment. Understanding the reasons why an individual chooses to seek treatment or prefers one treatment to another is a critical step to improve treatment seeking. To begin to understand these reasons, we conducted a qualitative analysis of the reasons women gave for choosing a cognitive-behavioral treatment, prolonged exposure (PE), or a pharmacological treatment, sertraline (SER). A community sample of women with trauma histories were asked to view standardized rationales, to choose among PE, SER, or no treatment, and to give 5 reasons for their choice. Women indicated that they were more likely to prefer the psychotherapy to the medication. Across reasons given, the most commonly cited reason for treatment preference highlighted why or how the treatment worked (e.g., I need to talk about it); and this reason emerged as the strongest predictor of preference for PE. Understanding this role of perceived treatment mechanism may aid clinicians and public health policy officials to identify and address help-seeking barriers regarding treatment.

Psychotherapies for hypochondriasis

BACKGROUND

Hypochondriasis is associated with significant medical morbidity and high health resource use. Recent studies have examined the treatment of hypochondriasis using various forms of psychotherapy.

OBJECTIVES

To examine the effectiveness and comparative effectiveness of any form of psychotherapy for the treatment of hypochondriasis.

SEARCH STRATEGY

1. CCDANCTR-Studies and CCDANCTR-References were searched on 7/8/2007, CENTRAL, Medline, PsycINFO, EMBASE, Cinahl, ISI Web of Knowledge, AMED and WorldCat Dissertations; Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register and clinicaltrials.gov; 2. Communication with authors of relevant studies and other clinicians in the field; 3. Handsearching reference lists of included studies and relevant review articles, and electronic citation search in ISI Web of Knowledge for all included studies.

SELECTION CRITERIA

All randomised controlled studies, both published and unpublished, in any language, in which adults with hypochondriasis were treated with a psychological intervention.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors using a standardised extraction sheet. Study quality was assessed independently by the two authors qualitatively and using a standardised scale. Meta-analyses were performed using RevMan software. Standardised or weighted mean differences were used to pool data for continuous outcomes and odds ratios were used to pool data for dichotomous outcomes, together with 95% confidence intervals.

MAIN RESULTS

Six studies were included, with a total of 440 participants. The interventions examined were cognitive therapy (CT), behavioural therapy (BT), cognitive behavioural therapy (CBT), behavioural stress management (BSM) and psychoeducation. All forms of psychotherapy except psychoeducation showed a significant improvement in hypochondriacal symptoms compared to waiting list control (SMD (random) [95% CI] = -0.86 [-1.25 to -0.46]). For some therapies, significant improvements were found in the secondary outcomes of general functioning (CBT), resource use (psychoeducation), anxiety (CT, BSM), depression (CT, BSM) and physical symptoms (CBT). These secondary outcome findings were based on smaller numbers of participants and there was significant heterogeneity between studies.

AUTHORS' CONCLUSIONS

Cognitive therapy, behavioural therapy, cognitive behavioural therapy and behavioural stress management are effective in reducing symptoms of hypochondriasis. However, studies included in the review used small numbers of participants and do not allow estimation of effect size, comparison between different types of psychotherapy or whether people are "cured". Most long-term outcome data were uncontrolled. Further studies should make use of validated rating scales, assess treatment acceptability and effect on resource use, and determine the active ingredients and nonspecific factors that are important in psychotherapy for hypochondriasis.

Parents’ perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders

Cognitive-behavioral therapy (CBT) and pharmacotherapy are the most well-established treatments for childhood anxiety disorders. This study examined how parents (N=71) seeking treatment for their child's anxiety disorder perceive the acceptability, believability, and effectiveness of these treatments. While both treatments were perceived favorably, CBT was rated as more acceptable, believable, and effective in the short- and long-term. Children's treatment history influenced parents' perceptions of pharmacotherapy, with parents of children with no treatment history perceiving medication treatment as less acceptable and believable than parents of children with a history of medication alone or in combination with behavior therapy. No effect of treatment history was found for perceptions of CBT. Significant positive correlations emerged between parents' perceived acceptance and believability for pharmacotherapy and child age and level of dysfunction due to their child's anxiety, respectively. The level of the child's anxiety was not significantly correlated with parents' perceptions of either CBT or pharmacotherapy. Our results suggest that parents of anxious children prefer CBT to medication for the treatment of their child's anxiety disorder. Directions for future research are discussed.

Listening to hypochondriasis and hearing health anxiety

Although hypochondriasis is categorized as a somatoform disorder in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition--Text Revision (DSM-IV-TR) due to excessive focus on bodily symptoms for at least 6 months, a contemporary conceptualization suggests that hypochondriasis represents an intense form of health anxiety. This article discusses the clinical presentation of hypochondriasis, etiological underpinnings and multiple maintaining factors, including physiological, cognitive and behavioral components. A cognitive-behavioral model of hypochondriasis as health anxiety and the empirically supported treatment based on the model are articulated. Future directions and informational resources are provided for both clinicians and patients.

Eliciting Patient Treatment Preferences: A Strategy to Integrate Evidence-Based and Patient-Centered Care

BACKGROUND

The integrated patient-centered evidence-based approach to care is integral to guide practice and enhance the quality of care. In this paper, a strategy to operationalize the integrated approach is described.

DESCRIPTION OF STRATEGY

The strategy flows from the processes used to synthesize the best available evidence for interventions that address a clinical problem, and to elicit patient preferences for treatment options, which is an important step in patient-centered care. The strategy consists of three phases: (1) synthesis of evidence about the effectiveness and relevance of interventions derived from research and practice; (2) generation of written material describing the nature, dose, effectiveness, and risks associated with the evidence-based interventions; and (3) using the written descriptions to elicit patient preferences. Examples from an ongoing study are presented to illustrate the implementation of the strategy within the context of research.

IMPLICATIONS

Nurses are invited to apply the strategy in practice and to evaluate its feasibility and utility in enhancing the quality of care.

Diagnostic and treatment interventions for hypochondriasis in the neurology setting

Many patients who present to neurology settings with somatic complaints have underlying fear of illness, anxiety, or depression. Hypochondriasis, which is one of the somatoform disorders, contributes to high use of services and frustration on the part of clinicians, because diagnostic and treatment interventions often fail. The challenges for clinicians include how to distinguish true somatic symptoms from those associated with fear or other psychiatric symptoms. Our goal is to provide the clinician with an integrated approach for the triage, assessment (history, screening tools, examination, and diagnostic tests), and treatment of these challenging patients. Recommendations are made regarding psychiatric consultation and comanagement between fields for complex patients.

Hypochondriasis: conceptualization, treatment, and relationship to obsessive-compulsive disorder

Once considered exclusively as a problem secondary to other mental dis-orders (ie, mood disorders), HC is now known to occur quite often as a pri-mary diagnosis. A frequent drain on medical resources, patients who have HC can be viewed as suffering essentially from an anxiety disorder in which intense fear is focused on the possibility that they might be seriously physically ill or that such illness is imminent. The processes that contribute to the development and maintenance of such health anxiety consist largely of beliefs, assumptions, and behavioral responses that, although internally consistent with the perception of health-related threat, are erroneous and highly maladaptive in that they prevent the correction of erroneous perceptions of threat. There is growing evidence that this conceptualization leads to effective reduction in HC symptoms through cognitive-behavioral and pharmacologic treatments. By far the main obstacle to successful treatment of HC is the patient's reluctance to view the problem as anything other than physical. The authors have found, however, that patients appreciate their care providers showing a genuine understanding of their concerns and taking the time to offer a logical, coherent explanation and rationale for the need for psychological and psychiatric services.

Current Directions in the Treatment of Hypochondriasis

Hypochondriasis was once considered treatment resistant. Recent studies, however, suggest that several interventions can be effective. This article presents a narrative review of psychosocial and pharmacologic treatments for hypochondriasis, supplemented by a meta-analysis of treatments to identify the most promising interventions. Findings suggest that cognitive behavior therapy is the most effective treatment for hypochondriasis. Fluoxetine also is promising, although the long-term effects of this and other medications remain to be examined. Psychoeducation appears to be sufficient for mild hypochondriasis. Future research on the mechanisms of hypochondriasis may shed light on how we can improve treatments, particularly for severe cases, which are least likely to benefit from psychosocial and drug interventions.

Gaps in accessing treatment for anxiety and depression: Challenges for the delivery of care

Epidemiological studies have identified high prevalence rates of anxiety and depression in North America [e.g., J. of Nerv. Ment. Dis. 182 (1994) 290]. However, only a small percentage of these individuals access effective treatment. The undertreatment of anxiety and depression is a major public health issue and is associated with significant personal, social, and economic burden. This article describes the existing discrepancy between prevalence of anxiety and depression and access to effective treatment for adults and children, the contributors to this discrepancy, and suggests various means through which access to effective treatment may be enhanced. We begin with a brief overview of the prevalence and associated personal, societal, and systemic burdens of anxiety and depression. This is followed by a review of current rates of access to treatment and possible individual, provider, and systemic barriers to accessing treatment. Recommendations for bridging the gap between the high rates of these disorders and limited accessibility of effective care are then presented.

The conflict between random assignment and treatment preference: implications for internal validity

The gold standard for most clinical and services outcome studies is random assignment to treatment condition because this kind of design diminishes many threats to internal validity. Although we agree with the power of randomized clinical trials, we argue in this paper that random assignment raises other, unanticipated threats to internal validity as a result of failing to consider treatment preference in research participant behavior. Treatment preference arises from an individual's knowledge and appraisal of treatment options. Treatment preferences impact: (1) the recruitment phase because people consider whether they want to participate in a study that involves the possibility of receiving an undesirable treatment or waiting for treatment, (2) degree of engagement in the intervention condition, and (3) attrition from the study. The benefits and limitations of research strategies that augment randomization while respecting treatment preference are reviewed including: approaches that enhance enrollment and engagement; pilot testing assumptions about randomization; and partially randomized clinical trials.

The relevance of health anxiety to chronic pain: research findings and recommendations for assessment and treatment

Health anxiety is a dimensional construct that is characterized by extreme concern about one's health at one end of the continuum and lack of concern about health on the other. Research evidence is consistent with the notion that high levels of health anxiety among patients with pain represent a poor prognostic indicator. Moreover, the experience of chronic pain can serve to increase health anxiety levels. This article concludes with a series of practical recommendations to assist practitioners in the assessment and management of patients with health anxiety.

Research to improve the quality of care for depression: alternatives to the simple randomized clinical trial

Recognition of gaps between evidence gained from mental health research and clinical practice in the community together with changes in treatment patterns and patient/provider preferences for care have led to interest in enhancements in the designs and analyses of clinical and community trials of mental health interventions. Gaps between clinical trials and community care include differences in populations and treatment strategies. To bridge these gaps, we propose enhancing the simple randomized trial with several different designs with the immediate aims of improving patient recruitment and adherence in psychiatric intervention studies thus bringing study designs more in line with clinical practice. The goals are to estimate treatment efficacy and effectiveness so that both internal and external validity are optimized. In this discussion, we address design and analytic issues with respect to a number of enhancements of the randomized trial design, including partial patient-provider preference designs, randomized encouragement and consent designs, fixed adaptive design, and random between- and within-patient adaptive designs. Each has advantages and disadvantages depending on the effect under investigation. Some of these enhancements, such as the fixed adaptive design, have begun to be implemented in effectiveness trials in mental health services research, but all are worthy of more attention.