Cognitive Behavior Therapy for Hypochondriasis: A Randomized Controlled Trial.
Barsky AJ and Ahern DK;
Commented by , 24 May 2004
Background
Hypochondriasis is a chronic, disabling, prevalent and costly illness generally viewed as refractory to treatment. Recent empiric evidence suggests distorted cognitions and bodily perceptions perpetuate the disorder.
Purpose
Evaluate the effectiveness of a cognitive behavior therapy (CBT) targeting the cognitive and behavioral amplification of somatic symptoms in hypochondriasis.
Methods
Randomized, usual care control group design. All subjects exceeded a pre-established cut-off score on the self-report Whiteley Index (WI) and Somatic Symptom Inventory. The intervention consisted of 6 weekly, 90-minute, tightly scripted individual CBT sessions.
A standardized consultation letter was also sent to patients’ primary care physicians to coordinate the CBT with ongoing medical management. The letter consisted of 5 practical suggestions: improved coping versus symptom elimination; schedule regular appointments to uncouple symptoms as the currency for care; limited reassurance; emphasize model of cognitive and perceptual symptom amplification; conservative approach to medical diagnosis and treatment.
Self-report measures of hypochondriacal beliefs, fears, attitudes, somatic symptoms and functional status were administered at baseline, 6 and 12-months post-treatment. Psychiatric and medical comorbidity was evaluated by standardized approaches. Using an intention-to-treat approach, analyses were a series of univariate and multivariate repeated measures analysis of covariance.
Results
Of 6307 individuals completing the screening questionnaire, 776 (12.3%) exceeded the cut-off. 156 proved ineligible, 219 declined and 214 were unreachable, leaving 187 participants. 102 were assigned to the intervention and 85 to usual care, with no between group differences at baseline. The mean duration of illness was 11 years.
At 12-month follow-up, CBT patients had significant improvement in hypochondriacal symptoms, beliefs, and attitudes (P<.001); health-related anxiety (P =.009); social role functioning (P =.05) and intermediate activities of daily living (P<.001). On the primary outcome, the WI, there was an effect size of r= 0.31 and 0.27, at 6- and 12-months, respectively.
Discussion
Several limitations bear consideration. As the authors acknowledge, generalizability is limited by the large proportion of eligible non-participants, who may have represented a group less amenable to a psychosocial intervention. The study setting, an academic institution with master’s and doctoral level therapists experienced in the model, also limits generalizability.
The specificity of the treatment effect warrants discussion. While fidelity to the model was monitored by randomly reviewing audiotaped sessions, it is unclear how this was determined. No mention is made of sessions being rated according to a standardized measure. With the abscence of a psychosocial control condition, it is possible that a nurturing atmosphere and positive expectations led to improvement.
Finally, the consultation letter to patients’ physicians makes it difficult to parse out treatment effect, as such approaches alone have led to improved functioning and healthcare costs (Ref. 1, 2).
Complementing the CBT with the consultation letter is also a major strength of the study. Effective communication with primary care physicians is requisite in the management of any somatoform disorder, reinforced by a symptom-based investigational and treatment approach. This letter is made available by the authors, and may be a useful template for correspondence with non-psychiatric physicians.
Notwithstanding the above noted limitations, this important study suggests that this chronic and disabling condition is in fact treatable, and responsive to a relatively simple but empirically-based and cost-effective intervention. Future studies evaluating more objective outcomes such as direct and indirect costs would be valuable.
References
- Rost K, Kashner TM, Smith GR Jr. Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. General Hospital Psychiatry 1994;16:381-387
- Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder: a randomized controlled study. New England Journal of Medicine 1986;314:1407-1413