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Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): A randomized controlled trial

Excessive health anxiety is associated with high levels of distress, disability and increased health care use.  It is common.  A recent study - "Health anxiety in Australia: prevalence, comorbidity, disability and service use" - reported "Health anxiety affects approximately 5.7% of the Australian population across the lifespan and 3.4% met criteria for health anxiety at the time of the interview ... Health anxiety was associated with significantly more distress, impairment, disability and health service utilisation than that found in respondents without health anxiety. Conclusions: Health anxiety is non-trivial; it affects a significant proportion of the population and further research and clinical investigation of health anxiety is required."  Other research has found varying prevalence rates of excessive health worry depending on the severity criteria being used, but there's general agreement that these disorders are common and debilitating.  It's noteworthy that a 2011 study - "Prevalence of health anxiety problems in medical clinics- screened over 23,000 people attending outpatient clinics and found 20% had significant health anxiety.

Understandably then, I have been interested for many years in how best to treat this disorder ... so I was fascinated by this summer's paper - "Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): A randomized controlled trial" - with it's intriguing summary "Objective: Cognitive-behavioral therapy has proven to be highly effective in the treatment of hypochondriasis and health anxiety. However, little is known about which therapeutic interventions are most promising. The aim of the present study was to compare the efficacy of cognitive therapy (CT) with exposure therapy (ET). Method: Eighty-four patients with a diagnosis of hypochondriasis were randomly allocated to CT, ET, or a waiting list (WL) control group. The primary outcome measure was a standardized interview that evaluated hypochondriacal cognitions as well as behaviors conducted by independent diagnosticians. Several self-report questionnaires were evaluated as secondary outcome measures. Treatment success was evaluated at posttreatment and at 1-year follow-up. Results: Both CT (Hedges's g = 1.01-1.11) and ET (Hedges's g = 1.21-1.24) demonstrated their efficacy in comparison with the WL in the primary outcome measure. Moreover, a significant reduction in depressive symptoms and bodily complaints was found in the secondary outcome measures for both treatments in comparison with the WL, but anxiety symptoms were only significantly reduced by ET. In a direct comparison, no significant differences were found between CT and ET in the primary or the secondary outcome measures. Regarding safety behaviors, we found a significantly larger improvement with ET than with CT in the completer analyses. Conclusions: The results suggest high efficacy of CT as well as ET in the treatment of hypochondriasis. Cognitive interventions were not a necessary condition for change of dysfunctional cognitions. These findings are relevant to the conceptualization and psychotherapeutic treatment of hypochondriasis and health anxiety."

This is good ... really encouraging results (although waiting list controls tend to inflate apparent outcomes) and the simpler exposure therapy treatment looks, if anything, to be a bit more effective than the fuller cognitive approach (which we already know is good - see last year's "Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-analysis of treatment outcome and moderators"). So what did the current trial's interventions involve?  Well the patients were pretty troubled, qualifying for a diagnosis of hypochondriasis rather than just health anxiety.  On average they had suffered their excessive fears - about cancer, heart disease, infections, neurological diseases, and so on - for about 13 years.  Treatment involved 12 initial weekly 50 minute sessions, followed by 3 further sessions at 1, 3 & 6 months after the last regular treatment session.  Cognitive therapy focused on reduction of dysfunctional health-related beliefs and included psychoeducation, cognitive restructuring, behavioral experiments, and imagery rescripting.  Behavior therapy "aimed to expose patients to stimuli that are relevant for health anxieties (e.g. documentaries about diseases) and to reduce avoidance behaviors (e.g. avoiding funerals) and safety behaviors (e.g. reassurance by doctors, checking the abdomen for cancer).  As in CT, Session 1 included information about the clinical picture of hypochondriasis. The roles of avoidance and safety behaviors for the maintenance of health anxieties were discussed with the patient. Sessions 2 to 4 focused on the reduction of safety behaviors (i.e., body checking, reassurance, and doctor visits). Patients were to reduce their safety behaviors step-by-step. Occurring problems were discussed with the therapist. Sessions 5 to 11 included the implementation of the treatment rationale for exposure (i.e., exposure to health-related stimuli, without using safety behaviors, leads to a reduction of health anxieties). Exercises of exposure included interoceptive exposure (e.g., hyperventilation), exposure in vivo (e.g., viewing documentaries about illness), and exposure in sensu (e.g., being confronted with images of being ill and one’s own death; see Furer & Walker, 2008, 2005). A more detailed description of the intervention is given elsewhere (Weck, Ritter, & Stangier, 2012). As in CT, Session 12 focused on relapse prevention and included the discussion on how to use exposure techniques for the time after treatment."  And, as previously noted, follow-up sessions were then scheduled at 1, 3 & 6 months after the final treatment session.  Remember though that all these patients qualified for a full diagnosis of hypochondriasis which involves a stricter set of criteria than for health anxiety.

The authors went on to write "Considering the clinical implications of the current study, CT and ET can be seen as effective treatment approaches for patients with hypochondriasis. However, specific cognitive interventions (e.g., cognitive restructuring) do not seem to be a necessary condition for achieving cognitive changes. In our study, we generally found higher effect sizes of ET than of CT, and a trend for superiority of ET over CT for the reduction of anxiety and safety behaviors was found. Moreover, effect sizes indicate that safety behaviors (behavioral subscale of the H-YBOCS) seem to change faster in ET than in CT (particularly when only including patients with a comorbid anxiety disorder). Therefore, on the basis of the current study, ET can be recommended as the preferential treatment approach, especially when patients have a comorbid anxiety disorder."  Well this all felt interesting enough for me to splash out and buy Neudeck & Wittchen's 2012 book "Exposure therapy: Rethinking the model - Refining the method".  This edited work contains chapters by many different authors including Weck, Ritter & Stangier's "Variants of exposure in body dysmorphic disorder & hypochondriasis" which contains more detail of the approaches used in this summer's cognitive therapy versus exposure therapy paper. Interestingly it seems that Weck & colleagues are a bit caught themselves between seeing exposure as producing habituation (the old behavioural view) and seeing it as disconfirming catastrophic expectations (the old cognitive view).  There seems little upgrading to a new associative, inhibitory learning understanding of exposure therapy's mechanisms of action.  In Neudeck & Wittchen's book there are three chapters on modern understandings of how exposure therapy works.  For example, Urcelay in "Exposure techniques: The role of extinction learning (p.58)" states "Extinction learning ... seems to be best captured as new learning for the relationship between stimuli and outcomes (including S-noO), rather than erasure of previously learned relationships."  I have started saying to clients something like "This desensitisation work we're doing is a bit like constructing a bypass around a town. The old stimulus-fear connection road will still be there going through the town, but we're going to construct a bigger, easier to travel bypass road that you'll be able to drive down much more comfortably & easily".  I wrote more about this last year with the post "Maximizing exposure therapy" on Michelle Craske's work and relevant too is the still earlier post on Nobel prizewinner Daniel Kahneman's research "Our minds work associatively: this is of central importance for psychotherapy and for life in general" . 

This is good stuff.  Hopefully it will advance the treatment of health anxiety disorder and ... wouldn't it be wonderful if it encouraged more therapists to adequately use exposure-based techniques (see, for example, the depressing findings from last year's paper "Has evidence-based psychosocial treatment for anxiety disorders permeated usual care in community mental health settings?")

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