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Long-Term Effect of Cognitive–Behavioural Therapy in Patients

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Long-Term Effect of Cognitive–Behavioural Therapy in Patients BJPsych Open (2020) 6, e42, 1–7. doi: 10.1192/bjo.2020.22 Long-term effect of cognitive–behavioural therapy in patients with Hypochondriacal Disorder Kari-Elise Frøystad Veddegjærde, Børge Sivertsen, Jens Christoffer Skogen, Otto Robert Frans Smith and Ingvard Wilhelmsen Background Cognitive–behavioural therapy (CBT) is an effective treatment for Conclusions Hypochondriacal Disorder, but the long-term effect has not been This uncontrolled treatment study suggests that patients treated examined extensively. with CBT for Hypochondriacal Disorder have significantly Aims reduced health anxiety 1 year after treatment completion and the results are maintained 10 years later. The results indicate that To investigate the long-term effect of CBT on Hypochondriacal CBT has a lasting effect, but the lack of a control group and use of Disorder using several mental health measures. Follow-up time only one therapist, means that care should be taken when gen- was at least 10 years. eralising the findings. Method A total of 50 patients with a long history of Hypochondriacal Keywords Disorder, diagnosed according to ICD-10, received 16 sessions of Cognitive behavioural therapies; anxiety disorders; outpatient individual CBT and were followed up with an uncontrolled treatment. design. All participants were assessed before and after the intervention period, and 10 years later. Intention-to-treat mixed- model repeated-measures analysis were conducted. The study Copyright and usage has been registered at clinicaltrials.gov: NCT00959452. © The Author(s) 2020. This is an Open Access article, distributed under the terms of the Creative Commons Attribution- Results NonCommercial-NoDerivatives licence (http://creativecommons. Patients displayed significant improvements across all out- org/licenses/by-nc-nd/4.0/), which permits non-commercial comes, including level of health anxiety, somatisation, symp- re-use, distribution, and reproduction in any medium, provided toms of anxiety and depression, quality of life, somatisation at the original work is unaltered and is properly cited. The written treatment completion. Treatment gains were well maintained 10 permission of Cambridge University Press must be obtained for years later. commercial re-use or in order to create a derivative work. Hypochondriacal Disorder Treatment of Hypochondriacal Disorder Hypochondriacal Disorder, or excessive health anxiety, involves Hypochondriacal Disorder was long thought of as an untreatable, persistent preoccupation with excessive worrying about having or lifelong condition. However, over past decades several studies have getting a serious illness.1 The patients focus on physical symptoms, shown beneficial short-term effect of cognitive–behavioural therapy keep track of all bodily changes and usually misinterpret these as (CBT) for Hypochondriacal Disorder10,11 but there is still a paucity signs of a serious illness.1,2 The worry and bodily preoccupation per- of studies examining if treatment gains are maintained over time. sists despite appropriate medical evaluation and reassurance.2,3 The To the best of our knowledge, only one study has followed patients prevalence of Hypochondriacal Disorder varies greatly across with Hypochondriacal Disorder beyond 1.5 years after treatment – studies, but has been found to be as high as 5.7% for lifetime completion.11 13 In a 5-year follow-up study of 444 UK patients Hypochondriacal Disorder, and 3.4% for current Hypochondriacal with Hypochondriacal Disorder, Tyrer et al found CBT to be a Disorder.2,4,5 The prevalence is substantially higher in primary highly effective treatment in reducing levels of health anxiety, as care settings than in the general population.2 Of note, in the latest well as symptoms of anxiety and depression at follow-up.11 revision of the DSM (DSM-5), the diagnosis of Hypochondriacal Disorder or hypochondriasis has been replaced by illness anxiety Study aim disorder. Untreated Hypochondriacal Disorder has a significant nega- Based on these considerations, the aim of the current study was to tive impact on the life of the people affected, with studies evaluate both the short- (18 months) and long-term (10 years) showing higher levels of comorbidity, distress, functional impair- effect of CBT on Hypochondriacal Disorder across different ment and increased risk of sick leave for patients reporting mental health outcomes. The study has been registered at clinical- Hypochondriacal Disorder.5 Patients with Hypochondriacal trials.gov with the protocol identifier NCT00959452. Disorder also have a higher level of healthcare utilisation, up to 78% higher than patients with well-defined medical conditions.6,7 These findings indicate that not only has Hypochondriacal Method Disorder a major impact on the lives of those affected, but it also represents a considerable cost for society.8 This was sup- Study design and participants ported by the finding in a large Norwegian population study The study had an uncontrolled, repeated-measures design. Patients that Hypochondriacal Disorder was a potent risk factor for were selected from the Hypochondriac Clinic at Haraldsplass 9 future permanent disability pension. Deaconal Hospital, in Bergen, Norway, from 1996 to 2001. The 1 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 23:22:40, subject to the Cambridge Core terms of use. Veddegjærde et al clinic opened in 1995, only 1 day a week. The clinic receives patients could withdraw from the study at any time, without giving any from all of Norway after referral from general practitioners, medical reasons for why they might want to withdraw from the study. specialists or psychologists. Patients from Bergen were offered 16 ses- This would not affect their further therapy. sions of CBT whereas patients from other parts of Norway were offered fewer sessions. Before treatment the patients were diagnosed Instruments and measures using the World Health Organization’s Composite International Whiteley Index, 14-item and 6-item versions Diagnostic Interview (CIDI),14 a structured interview for psychiatric disorders according to ICD-10.1 All patients fulfilled the diagnostic The Whiteley Index, a 14-item Likert questionnaire, is a self-report criteria for Hypochondriacal Disorder (F45.2)1 as their primary diag- measure to screen for Hypochondriacal Disorder. It was first used by nosis. Patients were excluded if they had a serious somatic illness, had Pilowsky in 1969, and has been widely used for the screening of 18 psychosis or were diagnosed with alcohol and/or substance misuse. Hypochondriacal Disorder. The Whiteley Index has been found to Baseline data were collected at the start of therapy and all patients have good psychometric properties, although the factor structure has 19 received 16 sessions of individual CBT, each session lasting 45–50 been questioned. The Whiteley Index consists of 14 items that origin- min, given over a period of 8–12 months. Patients were included ally were used dichotomously (true/false). A 5-point Likert scale version in the long-term follow-up study at the scheduled control 1 year was later established, with the response options labelled as follows: 1, ‘not after the last session and because of the relatively long treatment at all’;2,‘to some extent’;3,‘moderately’;4,‘to a considerable extent’;and and follow-up period only patients from the Bergen area were 5, ‘toagreatextent’. The dichotomous version of the Whiteley Index is included in the study. The first 50 patients who fulfilled the diagnos- still the version mostly used, although the Likert scale version is claimed 20 tic criteria for Hypochondriacal Disorder, had not developed any to differentiate better than the dichotomous version. The version serious somatic disease during the treatment period and agreed to employed in the current study includes the Likert scaled response participate in the long-term follow-up were included. Two patients options. In a recent Norwegian study a shorter version of the Whiteley withdrew during the follow-up period and their data were excluded Index, including only six items, was found to have better psychometric 19 from the analysis. No patients died during the study period. properties than the original 14-item version. In the current study, One therapist (I.W.) treated all the patients in this study. I.W. was both the 6-item and the original 14-item Whiteley Index were used. educated in CBT ad modum Aaron Beck, and he is a certified super- Cronbach’s alphas were 0.93 at all three assessment points. visor of CBT in The Norwegian Association of Cognitive Therapy and a member of Academy of Cognitive Therapy. The therapist did not Next-of-kin questionnaire focus on the physical symptoms presented, but rather examined For the purposes of the present study, we adapted the Whiteley and questioned how the patients interpreted their symptoms. Index to be filled out by the participants’ partner or a close relative. Research has found that reassurance has a negative effect on This next-of-kin-questionnaire is a Likert-scale questionnaire, with 15 Hypochondriacal Disorder, which is supported by the fact that a response scale of 1–5, where 1 equals ‘not at all’, and 5 is ‘to a great the patients in this study had the condition for more than a decade, extent’, similarly to the Whiteley Index. The questionnaire estimates in spite of numerous consultations with doctors, multiple tests and the patient’s health complaints from a next-of-kin perspective. The medical examinations. Cronbach’s alphas in the current study
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