Response and Remission After Cognitive and Exposure Therapy for Hypochondriasis

Exposure therapy for health anxiety: Effectiveness and response rates in routine care of an outpatient clinic

OBJECTIVE

Many randomized controlled trials (RCTs) have demonstrated the efficacy and benefits of exposure therapy in the treatment of health anxiety. However, the application of these research results to routine care has not been considered sufficiently. The aim of this study is to analyze the effectiveness of exposure therapy in the routine treatment of health anxiety patients.

METHOD

Data were available for 35 patients, who repeatedly filled in comprehensive general questionnaires, and those specific to health anxiety.

RESULTS

The data analysis showed that health anxiety symptoms decreased significantly both posttreatment (Cohen's d = 0.97-1.00) and at follow-up (Cohen's d = 1.33-1.34). In addition, the scores of depressiveness, somatic symptoms, and psychological distress showed improvements with effect sizes of d = 0.35-0.51. Regarding the primary outcome measures for health anxiety, response rates were 51%-63%, and remission rates were 29%-43%.

CONCLUSION

Exposure therapy is effective and sustainable regarding the treatment of health anxiety, even under naturalistic conditions, whereas response and remission rates are lower than for RCT.

The Amplification of Symptoms in the Medically Ill

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Illness Anxiety Disorder: Psychopathology, Epidemiology, Clinical Characteristics, and Treatment

Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms. An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collaboration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.

A Randomized Controlled Trial of Medication and Cognitive-Behavioral Therapy for Hypochondriasis

OBJECTIVE

Prior studies of hypochondriasis demonstrated benefits for pharmacotherapy and for cognitive-behavioral therapy (CBT). This study examined whether joint treatment offers additional benefit.

METHOD

Patients with DSM-IV hypochondriasis (N=195) were randomly assigned to one of four treatments-placebo, CBT, fluoxetine, or joint treatment with both fluoxetine and CBT. Evaluations assessed hypochondriasis, other psychopathology, adverse events, functional status, and quality of life. The primary analysis assessed outcome at week 24 among the intent-to-treat sample, with responders defined as having a 25% or greater improvement over baseline on both the Whiteley Index and a modified version of the Yale-Brown Obsessive Compulsive Scale for hypochondriasis (H-YBOCS-M). The Cochran-Armitage trend test assessed the hypothesized pattern of response: joint treatment > CBT or fluoxetine treatment > placebo treatment.

RESULTS

The predicted pattern of response was statistically significant, as shown by the following responder rates: joint treatment group, 47.2%; single active treatment group, 41.8%; and placebo group, 29.6%. Responder rates for each active treatment were not significantly different from the rate for placebo. Secondary analyses of the Whiteley Index as a continuous measure revealed that, compared with placebo, fluoxetine (but not CBT) was significantly more effective at week 24 in reducing hypochondriasis and had a significantly faster rate of improvement over 24 weeks. Fluoxetine also resulted in significantly less anxiety and better quality of life than placebo. Dropout rates did not differ between groups, and treatment-emergent adverse events were evenly distributed.

CONCLUSIONS

This study supports the safety, tolerance, and efficacy of fluoxetine for hypochondriasis. Joint treatment provided a small incremental benefit. Because approximately 50% of patients did not respond to the study treatments, new or more intensive approaches are needed.

Patient Characteristics and Patient Behavior as Predictors of Outcome in Cognitive Therapy and Exposure Therapy for Hypochondriasis

OBJECTIVE

Psychotherapy for hypochondriasis has greatly improved over the last decades and cognitive-behavioral treatments are most promising. However, research on predictors of treatment outcome for hypochondriasis is rare. Possible predictors of treatment outcome in cognitive therapy (CT) and exposure therapy (ET) for hypochondriasis were investigated.

METHOD

Characteristics and behaviors of 75 patients were considered as possible predictors: sociodemographic variables (sex, age, and cohabitation); psychopathology (pretreatment hypochondriacal symptoms, comorbid mental disorders, and levels of depression, anxiety, and somatic symptoms); and patient in-session interpersonal behavior.

RESULTS

Severity of pretreatment hypochondriacal symptoms, comorbid mental disorders, and patient in-session interpersonal behavior were significant predictors in multiple hierarchical regression analyses. Interactions between the predictors and the treatment (CT or ET) were not found.

CONCLUSIONS

In-session interpersonal behavior is an important predictor of outcome. Furthermore, there are no specific contraindications to treating hypochondriasis with CT or ET.