Group cognitive and behavioural treatment for hypochondriasis Richard Stern, Margaret Fernandez Abstract various thermometers. Reassurance from doctors Objective-To assess the feasibility of carrying about this type of behaviour can make the problem out group cognitive and behavioural treatment for worse.4 hypochondriasis in a general hospital setting. Design-Assessment of patients referred for therapy. Subjects and methods Setting-District general hospital. We recruited patients to the study by informing all Patients-Six patients aged 35 to 55 (mean 43) the hospital's consultants of the availability of a new years with a mean duration of symptoms of 12 years treatment for hypochondriasis. All patients entered who fulfilled the Diagnostic and Statistical Manual into treatment had to be referred by a consultant, aged for Mental Disorders (DSM III-R) criteria for hypo- 18-65 years, and had to fulfil the criteria for hypo- chrondriasis. chondriasis in the third revision of the Diagnostic and Main outcome measures-Number of visits to Statistical Manualfor Mental Disorders (DSM III-R).s their doctors, time spent thinking about iliness, and These criteria were (a) preoccupation with the fear of scores on the hospital anxiety and depression scales. having, or the belief that one has, a serious disease, Results-The mean number of visits to a doctor based on interpretation of physical signs or sensations fell significantly after treatment (3 before treatment v as evidence ofphysical illness; (b) appropriate physical 0O8 after treatment; p=003) as did the time spent evaluation does not support the diagnosis of any thinking about illness (57.3 v 40X6; p=0-14). The physical disorder that can account for the physical depression and anxiety scores also fell, although the signs or sensations or the person's unwarranted inter- differences were not significant (depression: 9-5 pretation ofthem, and the symptoms are not just those before v 8-5 after; anxiety: 13 before v 12 after). ofpanic attacks; (c) the fear ofhaving, or the beliefthat Conclusion-It is feasible to carry out group one has, a disease persists despite medical reassurance; cognitive and behavioural treatment in patients with (d) duration of the disturbance is at least six months; hypochondriasis, and controlled studies are now (e) beliefinthe symptoms is not ofdelusional intensity, indicated. as in somatic type delusional disorder-that is, the person can acknowledge the possibility that his or her fear of having, or the belief that he or she has, a Introduction serious disease is unfounded. Cognitive educational treatment for hypochondria- All the patients were told they would be offered a sis, was first proposed by Barsky and colleagues 2 but course in stress management. patients with hypochondriasis are usually reluctant to Patients were assessed with the hospital anxiety and accept referral to a psychiatrist because they consider depression scale.6 To determine the amount of medical their condition to be due to some undiscovered disease. attention patients received they were asked to state The concept ofstress has become widely known among how often they had visited any doctor in the previous the general public, and for this reason patients are month. We also devised a scale to measure the amount likely to accept a course of therapy labelled stress of time patients spent thinking about illness. It management, although they would probably refuse a consisted of a line 10 cm long, at one end of which was psychiatric referral. As hypochondriac patients take written "no time at all" and at the other end "24 hours up a lot of primary carers' and other doctors' time' a day." Patients were asked to place a mark on this line we decided to test the feasibility of a group cognitive to represent the time spent thinking about illness at the and behavioural therapy programme, described to time of the rating. All these ratings were administered patients as stress management, in a district general three to six months before treatment (baseline hospital. The programme was conducted in a hos- measures), just before the first group treatment, after pital to emphasise the medical rather than psychiatric the last treatment, and at six months' follow up. milieu. Hypochondriasis is a learnt behaviour in which the TREATMENT patient focuses unduly on a particular symptom, or set We treated patients weekly for nine sessions, each of symptoms, and continued medical investigation lasting one and a half hours. The structure of the serves to reinforce this. Group treatment was carried sessions was as follows. out to show patients that they were not unique in Session I -We told patients that their treatment St Helier Hospital, having this problem and also because it was hoped that would go beyond stress management so that they could Carshalton, Surrey patients would help each other become less self understand how the symptoms arose as well as how to SM5 1AA centred. cope with stress. Education started with an acknow- Richard Stern, FRCPSYCH, The cognitive and behavioural hypothesis proposes ledgment that the symptoms really existed-and that consultant psychiatrist that three mechanisms act in preoccupation with the treatment aimed to explain them satisfactorily. Margaret Fernandez, illness. Firstly, increased autonomic arousal occurs, Patients were helped to distinguish between helpful, MRCPSYCH, consultant and this is interpreted by the patients that they are relevant information and reassurance with repetitive psychiatr'st unwell. Secondly, the patients focus their attention on information. The patients were told that further some of function. investigations were not part of this new treatment, and Correspondence to: Dr normal variation physiological R Stern, Springfield Thirdly, an obsessive checking behaviour develops. we proposed that they commit themselves to working University Hospital, For example, one ofour patients was preoccupied with in the group along these new lines for the nine weeks. London SW17 7DJ. minor variations in her temperature and became We had less difficulty in negotiating this agreement convinced that this represented something serious and than expected. Patients expressed considerable anger BJIJ 1991;303:1229-31 checked her temperature several times each day with with their doctors for suggesting their symptoms were BMJ VOLUME 303 16 NOVEMBER 1991 1229 "all in the mind," but they recognised the compulsion less reassurance from doctors-one patient reported to visit doctors, which some of them likened to an that her general practitioner had telephoned her to addiction. inquire why she had not attended. The possibility of Session 2-The attention focus aspect of hypochon- positive change despite most patients' negative past driasis was emphasised. One of us illustrated this by experiences was brought out in the group. This asking the group to focus on their throats, which irrationality has been expressed by Ellis: "The idea induced swallowing in most patients and a mild attack that one's past history is an all-important determiner of of coughing in the group. One patient stated that he one's present behaviour and that because something had backache in the office but not when he went once strongly affected one's life, it should indefinitely fishing. The well known hypochondriasis among have a similar effect."8 medical students was illustrated to emphasise how Session 9-Material from previous sessions was dealt widespread the phenomenon can be. We asked with. Some patients developed supportive bonds and patients to keep a symptom diary, to test further the these were encouraged, but care was taken to ensure attention focus theory. that mutual reassurance about symptoms was pre- Session 3-We taught patients relaxation exercises in vented. We asked patients to summarise what had been the group, and the instructions were tape recorded to said, to check that they understood the main points in enable further practice at home. The symptom diaries the treatment. The patient with a compulsion to check were discussed in the group, and patients were her temperature reported that she had thrown away her additionally asked to record any dysfunctional thought thermometers, but that on one occasion could not experienced at the time of a symptom. resist the urge and had had to go next door and borrow Session 4-The diaries were reviewed. One patient a neighbour's thermometer. could see the illogical assumptions another was making but not her own, and in this way group members helped each other. They received reassurance not only Results from doctors but from home medical encyclopaedias We recruited six patients (three men and three and television programmes. The group were found to women) to the study aged 35 to 55 (mean 43) years. The be fans of the television soap Casualty, set in an duration of symptoms ranged from 28 to seven (mean accident and emergency department, and the group 12) years. We thought six a suitable number for group were asked to watch and discuss the next episode and to treatment, and it took a year to recruit this number. try to identify the reassurance seeking behaviour in The patients each had a huge folder of case notes, each other. reflecting the burden they had placed on medical Session 5 -The role of relatives in providing reassur- services. ance was discussed. One patient constantly asked her The values obtained in the assessments of patients husband about her symptoms, and another asked his did not change significantly between the baseline and wife to sit on his knees to relieve joint pain. We pointed pretreatment measurements. This period ranged from out that this behaviour provided only short term relief three to six months (table). and led to an increased need for reassurance in the The difference between mean number ofvisits to the future. We asked patients what procedures would fully doctor before and after treatment was 2 2 (95% confi- convince them that they were not suffering from the dence interval 0 36 to 4 0), and the difference between feared illness.