Cognitive Behavior Therapy for Hypochondriasis a Randomized Controlled Trial
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ORIGINAL CONTRIBUTION Cognitive Behavior Therapy for Hypochondriasis A Randomized Controlled Trial Arthur J. Barsky, MD Context Hypochondriasis is a chronic, distressing, and disabling condition that is preva- David K. Ahern, PhD lent in ambulatory medical practice. Until recently, no specific treatment has been clearly demonstrated to be effective. YPOCHONDRIASIS IS DEFINED Objective To assess the efficacy of a cognitive behavior therapy (CBT) for hypo- as a persistent fear or belief chondriasis. that one has a serious, un- Design A randomized, usual care control group design, conducted between Sep- diagnosed medical illness. tember 1997 and November 2001. The individual primary care physician was the HOccurring in as many as 5% of medi- unit of randomization, and all patients clustered within each physician’s practice cal outpatients, it is a prevalent, dis- were assigned to the experimental treatment (individual CBT and a consultation let- abling, and chronic condition that has ter to the primary care physician) or to the control condition. Subjects were generally been refractory to psycho- assessed immediately before and 6 and 12 months after the completion of treat- logical and pharmacological treat- ment. ment and costly for the health care sys- Setting and Participants Participants were 80 patients from primary care prac- tem.1-6 Until recently, there was no tices and 107 volunteers responding to public announcements, all of whom exceeded empirically validated treatment for the a predetermined cutoff score on a hypochondriasis self-report questionnaire on 2 suc- hypochondriacal patient’s somatic cessive occasions. symptoms, belief in the presence of an Intervention A scripted, 6-session, individual CBT intervention was compared with undiagnosed disease, health-related medical care as usual. The CBT was accompanied by a consultation letter sent to the anxiety, and bodily preoccupation. Al- patient’s primary care physician. though limited by small samples, lack Main Outcome Measures Hypochondriacal beliefs, fears, attitudes, and somatic of randomization and control groups, symptoms; role function and impairment. the absence of long-term follow-up, lim- Results A total of 102 individuals were assigned to CBT and 85 were assigned to ited generalizability, and the absence of medical care as usual. The sociodemographic and clinical characteristics of the 2 groups validated outcome measures,7-12 the ex- were similar at baseline. Using an intent-to-treat analytic strategy, a consistent pat- isting treatment literature suggests a tern of statistically and clinically significant treatment effects was found at both 6- and role for a variety of psychosocial inter- 12-month follow-up, adjusting for baseline covariates that included educational level, ventions, although none has been con- generalized psychiatric distress, and participant status (patient vs volunteer). At 12- month follow-up, CBT patients had significantly lower levels of hypochondriacal symp- clusively validated. In the only large- toms, beliefs, and attitudes (PϽ.001) and health-related anxiety (P=.009). They also scale, rigorous, randomized controlled had significantly less impairment of social role functioning (P=.05) and intermediate trial to date, cognitive therapy and be- activities of daily living (PϽ.001). Hypochondriacal somatic symptoms were not im- havioral stress management were both proved significantly by treatment. more effective than a waiting list con- Conclusion This brief, individual CBT intervention, developed specifically to alter hy- 13 trol condition. pochondriacal thinking and restructure hypochondriacal beliefs, appears to have sig- We have proposed that hypochon- nificant beneficial long-term effects on the symptoms of hypochondriasis. driasis can be understood as a self- JAMA. 2004;291:1464-1470 www.jama.com perpetuating and self-validating disorder of cognition and bodily per- 14-16 Author Affiliations: Department of Psychiatry, Brigham Corresponding Author: Arthur J. Barsky, MD, Depart- ception. In this formulation, per- and Women’s Hospital and Harvard Medical School, ment of Psychiatry, Brigham and Women’s Hospital, sonally threatening life events prompt Boston, Mass. 75 Francis St, Boston, MA 02115 ([email protected]). 1464 JAMA, March 24/31, 2004—Vol 291, No. 12 (Reprinted) ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 COGNITIVE BEHAVIOR THERAPY FOR HYPOCHONDRIASIS predisposed individuals to suspect that The precise cutoff score of 150 (score cantly in the next 12 months; somato- they have become ill. This suspicion range, 52-258) was determined from form pain disorder; psychosis or sui- leads them to selectively attend to be- previous studies3,17-19 and was chosen cide risk; and ongoing, symptom- nign bodily sensations and health in- because we believed that many sub- contingent, disability determinations, formation that confirm their suspi- threshold individuals were sufficiently workers’ compensation proceedings, or cion and to ignore disconfirmatory hypochondriacal to be in need of treat- litigation. evidence. Benign bodily sensations are ment and would be able to benefit from thereby amplified and misattributed to it. Signed informed consent was ob- Treatment Conditions the putative disease, which further sub- tained in accordance with the Brigham and Therapists stantiates their disease convictions. We and Women’s Hospital Human Re- Cognitive behavior therapy was admin- have developed a cognitive behavior search Committee requirements. Sub- istered individually in six 90-minute ses- therapy (CBT) that specifically targets jects meeting initial eligibility criteria and sions at weekly intervals. Each session the cognitive and behavioral amplifi- exceeding the screening cutoff com- was tightly scripted (manual available ers of benign bodily symptoms that pleted the baseline research battery, from the authors) and devoted to 1 of 5 propel this hypochondriacal cycle of which included a second administra- factors that cause patients to amplify so- disease conviction and symptom am- tion of the screening questionnaire and matic symptoms and misattribute them plification. Patients are helped to cor- a determination of their medical mor- to serious disease: attention and bodily rect faulty symptom attributions, re- bidity. hypervigilance, beliefs about symptom structure beliefs and expectations about Physicians were randomized imme- etiology, circumstances and context, ill- health and disease, correct misunder- diately following the baseline re- ness and sick role behaviors, and mood. standings about the medical care pro- search interview by a staff member not Each session consisted of educational in- cess, modify maladaptive illness behav- connected to the research, using a ran- formation about the symptom amplifi- iors, and learn techniques of selective dom numbers table. Randomization was ers, an illustrative exercise, and a dis- attention and distraction. stratified by physician seniority (house cussion to personalize the material We hypothesized that the CBT in- staff or attending staff) and by prac- presented. The 3 study therapists had tervention would alleviate the symp- tice volume (part-time or full-time for master’s or doctoral degrees and prior toms of hypochondriasis more effec- attending staff, primary care program CBT experience. Treatment sessions tively than medical care as usual. or traditional internal medicine pro- were held in offices in the department gram for house staff). All research data of psychiatry. METHODS were collected by research assistants Because it was considered essential Study Design who were blind to the patient’s treat- that the patients’ ongoing medical man- A randomized, usual care control group ment status, and the study therapists agement be coordinated with the CBT design was used. To avoid a “contami- and investigators had no foreknowl- to alter their understanding of symp- nation” effect, the individual primary edge of treatment assignment. The toms, disease, and medical care, a stan- care physician was the unit of random- therapists had no role in data collec- dardized consultation letter was sent to ization, and all patients clustered within tion. Subjects were compensated for each patient’s primary care physician. each physician’s practice were as- each research interview, but not for un- This letter (available from the authors) signed to the experimental treatment dergoing treatment. contained the following 5 practical sug- (individual CBT and a consultation let- gestions for medical management that ter to the primary care physician) or to Subjects and Settings were designed to augment the indi- the control condition. Subjects were Subjects were accrued from 2 sources: vidual therapy: (1) make improved cop- assessed immediately before and 6 (1) successive patients attending ing with somatic symptoms rather than and 12 months after the completion of primary care practices in 2 large, aca- symptom elimination the goal of medi- treatment. demic medical centers, and (2) volun- cal management; (2) uncouple access to Subjects were recruited by screening teers responding to public announce- the physician from symptom status by with a self-report hypochondriasis ques- ments of a treatment study for “health scheduling regular appointments; (3) tionnaire (composed of the Whiteley anxiety and hypochondriasis.” provide only limited reassurance; (4) ex- Index and Somatic Symptom Inventory), The inclusion criteria were age