Hypochondriasis. Medical management and psychiatric treatment

Telephone interpersonal counseling treatment for frequent attenders to primary care: Development and piloting

BACKGROUND

Frequent attenders in primary care (FAs) consume a disproportionate amount of healthcare resources and often have depression, anxiety, chronic health issues, and interpersonal problems. Despite extensive medical care, they remain dissatisfied with the care and report no improvement in quality of life.

OBJECTIVE

To pilot a Telephone-based Interpersonal Counseling intervention for Frequent Attenders (TIPC-FA) and assess its feasibility and efficacy in reducing symptoms and healthcare utilization.

METHOD

Top 10% of primary care visitors were randomly assigned to TIPC-FA, Telephone Supportive Contact (Support), or Treatment as Usual (TAU). TIPC-FA and Support groups received six telephone sessions over twelve weeks, while the TAU group was interviewed twice. Multilevel regression tested for changes over time, considering patient and counselor variance.

RESULTS

TIPC-FA and Support groups demonstrated reduced depressive symptoms, and the TIPC-FA group showed decreased somatization and anxiety. The TIPC-FA group demonstrated a trend towards less healthcare utilization than the TAU group.

CONCLUSION

This pilot study suggests that IPC via telephone outreach is a feasible approach to treating FAs, achieving a reduction in symptoms not seen in other groups. Promising reduction in healthcare utilization in the TIPC-FA group warrants further exploration in larger-scale trials.

The management of somatisation

Somatisation remains a matter of bewilderment in medicine. Medical students have trouble defining it, psychiatry trainees wilt in its presence, and all doctors are prone to become entangled in it. The current spate of reviews on the topic is appropriate (Mayou et al, 1995a; Barsky, 1996; Gill & Bass, 1996). There is a great need for those required to manage patients with ‘medically unexplained symptoms’ to be informed sufficiently to take a stance on the theoretical issues involved and develop appropriate management plans.

Implementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting

Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.

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.

A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis

BACKGROUND

Hypochondriasis is common in the clinic and in the community. Cognitive behavioural therapy (CBT) has been found to be effective in previous trials. Psychodynamic psychotherapy is a treatment routinely offered to patients with hypochondriasis in many countries, including Denmark. The aim of this study was to test CBT for hypochondriasis in a centre that was not involved in its development and compare both CBT and short-term psychodynamic psychotherapy (STPP) to a waiting-list control and to each other. CBT was modified by including mindfulness and group therapy sessions, reducing the therapist time required. STPP consisted of individual sessions.

METHOD

Eighty patients randomized to CBT, STPP and the waiting list were assessed on measures of health anxiety and general psychopathology before and after a 6-month treatment period. Waiting-list patients were subsequently offered one of the two active treatments on the basis of re-randomization, and assessed on the same measures post-treatment. Patients were again assessed at 6- and 12-month follow-up points.

RESULTS

Patients who received CBT did significantly better on all measures relative to the waiting-list control group, and on a specific measure of health anxiety compared with STPP. The STPP group did not significantly differ from the waiting-list group on any outcome measures. Similar differences were observed between CBT and STPP during follow-up, although some of the significant differences between groups were lost.

CONCLUSIONS

A modified and time-saving CBT programme is effective in the treatment of hypochondriasis, although the two psychotherapeutic interventions differed in structure.

Cognitive behavioral therapy for somatoform disorders

Patients presenting with somatoform disorders often incur excessive health care charges and fail to respond to standard treatment. The purpose of this article is to provide an overview of the diagnostic criteria and demographic and clinical characteristics of each somatoform disorder and to examine the research assessing the efficacy of cognitive behavioral therapy (CBT) for each disorder. The review shows that CBT has received some empirical support for somatization, hypochondriasis, and body dysmorphic disorder. However, there are few data on the impact of treatment on health care use, especially when the cost of CBT is factored into the equation. Too few methodologically sound studies have been published on the treatment of conversion disorder or of pain disorder to make any conclusions.

A One-Session Treatment for Patients Suffering From Medically Unexplained Symptoms in Primary Care: A Randomized Clinical Trial

The aim of the study was to evaluate a one-session cognitive-behavior treatment (CBT) versus standard medical care for 140 primary-care patients with multiple somatoform symptoms. DSM-IV diagnoses were assessed with structured interviews. Primary outcome variables were healthcare utilization, number, and severity of somatoform symptoms, and secondary outcome measures were psychopathology dimensions. Assessments were done at study enrollment, at 4-weeks, and at 6-month follow-up. General acceptance of CBT was high (positive session evaluations, low dropout rate: 15%). Using an intent-to-treat analytic strategy, both groups improved. Yet results showed a stronger reduction in doctor visits and somatization severity in CBT versus standard 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.

An open-label clinical trial of nefazodone in hypochondriasis

Hypochondriasis is a common and challenging problem in general medical practice, but little research is available on pharmacotherapeutic treatment approaches. The purpose of the present study was to evaluate the use of nefazodone in the treatment of hypochondriasis in an open-label trial. Eleven patients with a primary diagnosis of DSM-IV hypochondriasis received an 8-week trial of nefazodone with a maximum dose of 600 mg/day and a mean dose of 432 mg. Clinician and self-ratings were completed at each of six visits. Nine of the 11 patients who started the trial completed 8 weeks of treatment. Five of the nine patients completing the trial were rated as much or very much improved on the clinician-rated global improvement scale. Self-ratings indicated statistically significant improvement on the Illness Attitudes Scales-Total Score (P <.01) and the Beck Depression Inventory (P <.04), and there was a trend toward improvement on the Whiteley Index (P <.06). The results of this study suggest that nefazodone is a promising treatment for hypochondriasis. More extensive evaluation in longer open-label trials and double-blind, placebo-controlled trials would be warranted.

Hypochondriasis: the patient's perspective

OBJECTIVE

The purpose of this investigation was to learn how patients with hypochondriasis view their physicians and medical care.

METHOD

To accomplish this, we identified 20 patients with DSM-III-R hypochondriasis and 26 nonhypochondriacal patients from a general medicine clinic. Using a semistructured interview, we obtained information from patients about their recent health problems and medical care. The investigators then reviewed transcribed interviews and assigned comments to a series of categories.

RESULTS

Hypochondriacal and non-hypochondriacal patients made equal numbers of positive comments, but hypochondriacal patients made significantly more negative comments about physicians' professional characteristics, characteristics of the patients themselves and total negative comments. Many viewed physicians they had seen as unskilled and uncaring. They indicated that, in many instances, their relationships with physicians had suffered from poor communication and collaboration.

CONCLUSION

Since successful management of patients with hypochondriasis rests upon positive relationships, ways must be found to improve the frustrating and costly situation that currently exists.

Somatization Disorder

There are many new developments regarding somatization disorder, which is among the most difficult and cumbersome of the psychiatric disorders encountered in neurology practice. Diagnostic criteria have been revised to facilitate clinical care and research. The differential diagnosis includes neurologic disorders (eg, multiple sclerosis, epilepsy), systemic medical disorders, and other psychiatric disorders (eg, mood and anxiety disorders, conversion disorder, malingering, and factitious disorder). Many patients have one or more of these illnesses comorbid with somatization disorder. Finally, somatization disorder demands creative biopsychosocial treatment planning by the neurologist, psychiatrist, and other health professionals.