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Randomised controlled trial.
Assessors blinded to treatment.
Follow up period:
Primary care practices, Boston, Mass., USA; September 1997 to November 2001.
187 people aged 18 years or older, scoring >150 (range 52–258) on the hypochondriasis screening questionnaire, who had consulted a primary care physician in the preceding 12 months. People who were seriously ill, psychotic, suicidal, suffering from somatoform pain disorder, or undergoing disability related proceedings or litigation, were excluded.
Six 90 minute weekly sessions of individual cognitive behavioural therapy, specifically addressing hypochondriasis and including educational information, or usual care. To coordinate medical management with cognitive behavioural therapy, letters were sent to the participants’ practioners, advising them to be conservative in diagnosis and treatment, schedule regular appointments, make improved coping a treatment goal rather than symptom elimination, provide only limited reassurance, and explain symptoms using the model of cognitive and perceptual symptom amplification.
Hypochondriacal attitudes and beliefs (The Whitely Index); health related anxiety (Health Anxiety Inventory).
Patient follow up:
86% at six months, 91% at 12 months.
At 12 months, cognitive behavioural therapy significantly decreased hypochondriacal attitudes and beliefs (p<0.001) and health related anxiety (p<0.009) compared with usual care (see http://www.ebmentalhealth.com/supplemental for table). Ability to function socially was significantly improved (p<0.05) as was the ability to perform normal daily activities (p<0.001). There were no significant differences in improvement of somatic symptoms between groups.
Cognitive behaviour therapy significantly improves the symptoms of hypochondriasis and may have long term benefits for sufferers.
This study claims to be the first to clearly look at the efficacy of CBT in a hypochondriacal patient population. Two groups participated: one which had six 90 minute sessions of CBT and the second group which received medical care as usual. In both groups, patients who fulfilled DSM IV criteria for hypochondriasis and those who only fulfilled subthreshold hypochondriasis were included. The primary care physicians of patients in the CBT group were asked to follow the following rules: (1) make improved coping with somatic symptoms rather than symptom elimination the goal of medical management; (2) schedule regular appointments; (3) provide only limited reassurance; (4) explain symptom amplification to the patient, and (5) be conservative in medical diagnosis and treatment. A total of 187 patients participated out of a total of 776 patients, of which 102 were in the CBT group and 85 in the medical as usual group. Not all patients completed the study. Of the 102 patients only 63 (61.8%) attended all six sessions and of the 85, 76 control patients (87% in person and 13% by telephone) completed the study. Results basically indicated that there was significant improvement in the treatment versus control group at both six and 12 months follow up. Hypochondriacal thoughts, health anxiety, and somatosensory amplification were all significantly improved via CBT. Only somatic symptoms were not significantly improved. This paper substantiates previous CBT studies in hypochondriasis1,3 that have shown CBT to be efficacious. Yaryura-Tobias & Neziroglu4 have also indicated that attrition rate is greater with behavioural rather than cognitive or medical treatment as usual forms of treatment, as this study has found. Suggestions for primary care physicians are well formulated and should be followed. It is the opinion of the reviewer that more than six sessions of CBT are necessary to make long term gains in most hypochondriacal patients.
For correspondence: Arthur J Barsky, Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts, USA;
Sources of funding: the National Institute of Mental Health.