Only 16 hours of cognitive behavioral therapy (CBT) can have very positive effects on hypochondriacs 10 years after treatment

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People that suffer from health anxiety (Hypochondriacs) use very much of their time and energy on checking whether or not they have a serious disease. This has often negative effects on their social life, work, and family life, to the extent that their quality of life is strongly reduced.

Researchers at the University of Bergen have found that only 16 hours of cognitive behavioral therapy (CBT) can have very positive effects on hypochondriacs 10 years after treatment.

“This is the first study that follows up hypochondriacs for such a long period. It shows that CBT has good effects both one year and 10 years after therapy,” says psychiatrist Kari-Elise Veddegjærde, Ph.D. candidate at the Department of Clinical Science at the University of Bergen (UiB). The study is published in The British Journal of Psychiatry.

In the study, Veddegjærde followed 50 patients that had struggled with health anxiety for a long time. Each received 16 hours of CBT from the well-known Norwegian therapist, Professor Ingvard Wilhelmsen at UiB.

The patients answered questionnaires about their quality of life before, during and after the treatment. Other therapies and their drug use was taken into account.

“We know that CBT is an effective treatment against health anxiety, but we did not know how long the effect would last. This study shows that the treatment maintains its positive effect over a long time period,” Veddegjærde says.

Veddegjærde is hoping that the results from the study will lead to more psychologists and psychiatrist offering CBT in the future. From her own practice, she has experienced that only a couple of hours is enough for some patients.

“Since the study shows that only a few hours with CBT has positive effects until 10 years after treatment, I hope that more regular GPs and specialists will start offering this type of treatment,” says Kari-Elise Veddegjærde.

Facts:Health anxiety and cognitive behavioral therapy

  • Health anxiety (hypochondria) is characterized by an ongoing belief that one has a serious disease or is going to have one. Often, the patient focuses on one specific disease. The most commonare cancer, heart disease and neurological disease.
  • The patients use a great deal of their time checking for disease symptoms.
    Approximately 3 percent of the persons visiting their GP suffer from hypochondria in Norway.
  • The aim of cognitive behavioral therapy (CBT) is to make patients more attentive to their unconscious mindset, by confronting the patients with questions. When the patients become more aware of their own thought patterns, it becomes possible to change them.

Hypochondriacal Disorder
Hypochondriacal Disorder, or excessive health anxiety, involves persistent preoccupation with excessive worrying about having or getting a serious illness.1 The patients focus on physical symptoms, keep track of all bodily changes and usually misinterpret these as signs of a serious illness.1,2 The worry and bodily preoccupation persists despite appropriate medical evaluation and reassurance.2,3

The prevalence of Hypochondriacal Disorder varies greatly across studies, but has been found to be as high as 5.7% for lifetime Hypochondriacal Disorder, and 3.4% for current Hypochondriacal Disorder.2,4,5

The prevalence is substantially higher in primary care settings than in the general population.2 Of note, in the latest revision of the DSM (DSM-5), the diagnosis of Hypochondriacal Disorder or hypochondriasis has been replaced by illness anxiety disorder.

Untreated Hypochondriacal Disorder has a significant negative impact on the life of the people affected, with studies showing higher levels of comorbidity, distress, functional impairment and increased risk of sick leave for patients reporting Hypochondriacal Disorder.5

Patients with Hypochondriacal 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 Disorder a major impact on the lives of those affected, but it also represents a considerable cost for society.8

This was supported by the finding in a large Norwegian population study that Hypochondriacal Disorder was a potent risk factor for future permanent disability pension.9

Treatment of Hypochondriacal Disorder
Hypochondriacal Disorder was long thought of as an untreatable, lifelong condition. However, over past decades several studies have shown beneficial short-term effect of cognitive–behavioural therapy (CBT) for Hypochondriacal Disorder10,11 but there is still a paucity of studies examining if treatment gains are maintained over time.

To the best of our knowledge, only one study has followed patients with Hypochondriacal Disorder beyond 1.5 years after treatment completion.11–13 In a 5-year follow-up study of 444 UK patients with Hypochondriacal Disorder, Tyrer et al found CBT to be a highly effective treatment in reducing levels of health anxiety, as well as symptoms of anxiety and depression at follow-up.11

Study aim
Based on these considerations, the aim of the current study was to evaluate both the short- (18 months) and long-term (10 years) effect of CBT on Hypochondriacal Disorder across different mental health outcomes. The study has been registered at clinicaltrials.gov with the protocol identifier NCT00959452.

Discussion
The aim of this small and uncontrolled treatment study was to investigate the short- and long-term effect of CBT on Hypochondriacal Disorder. In short, treated patients (n = 50) displayed significant improvements across all outcome measures, and treatment gains were well maintained even 10 years after treatment completion, suggesting that CBT may have lasting benefits for this patient group. Some important study limitations mean that care should be taken when generalising the results.

Several controlled clinical studies have found that CBT has a positive short-term effect in patients with Hypochondriacal Disorder. In a six-session individual CBT intervention, Barsky & Ahern found that the positive effect on Hypochondriacal Disorder was maintained at both 6- and 12-month follow-up.13

Greeven et al found sustained positive effect of CBT in an 18-month follow-up.29 In this long-term follow-up study we found that the short-term positive effect of 16 sessions of CBT at the 1-year follow-up were maintained after 10 years. Our findings are in line with the conclusion of a recent report from the National Institute of Health Research (NIHR) in the UK that included a 5-year follow-up of patients with Hypochondriacal Disorder receiving CBT.11

As the NIHR report showed, the treatment gains were evident across a range of mental and physical health domains, and not just limited to symptoms of Hypochondriacal Disorder. As a result of the lack of a control group and the long time-range between inclusion and end of our study we cannot conclude that the maintenance of the positive clinical status is attributed to CBT alone, but given the fact that the patients had a long history of Hypochondriacal Disorder, with a mean time of 11.3 years before receiving CBT, it is, in our opinion, a strong indication that the long-term treatment effect is positive. However, we cannot conclude that CBT is the only effective treatment since the study did not include other therapies.

The treatment gains displayed across all self-report questionnaires used in the current study was corroborated by the findings from the telephone interview carried out at the 10-year follow-up assessment, where as many as 58% of the patients no longer considered themselves as having Hypochondriacal Disorder.

Several studies have shown that patients with Hypochondriacal Disorder or excessive health anxiety are high utilisers of healthcare resources.2,6,30–32 As the condition in many patients with Hypochondriacal Disorder is left undetected and untreated,2,7 there may therefore be substantial socioeconomic benefits in improved diagnostic practices and treatment availability for this patient group.

However, the previously mentioned NIHR study found it difficult to show economic benefits for this in terms of quality-adjusted life-years,11 but the current study shows a significant improvement in quality of life.

Methodological limitations
Some important methodological limitations should be noted. Most importantly, the current study was not a randomised controlled trial. The lack of a control group means that we cannot disregard the possibility that the observed treatment effects may partly be because of time passing or regression to the mean.

As such, care should be taking when interpreting the results, and future studies should address this by also including a control group, preferably with an active comparison treatment group. By comparing our findings with trait existing national norms of the SF-36, the obvious weakness of not having a control group was somewhat addressed.

Furthermore, the statistical power of the current study is limited by a relatively small sample size, and larger studies will allow for more detailed analysis of potential moderators in the future. Also, some of the Cronbach’s alphas were less than optimal, and the results should be interpreted with this in mind.

Moreover, it should be mentioned that only one therapist (I.W.) was involved in treatment. Although this may limit the generalizability of the study, one could argue that continuity was maintained in treatment.

Finally, all instrument measures in the current study were based on self-report, and no clinician-verified information was included. However, the next-of-kin version of the Whiteley Index instrument displayed similar treatment gains, indicating the existence of treatment gains across informants.

Strengths
The current study has the longest follow-up in any Hypochondriacal Disorder treatment study, which is a significant study strength. Also, the drop-out rate across all three assessment points (from pre-treatment to 10-year follow-up) was only 14%, which is much lower than previous studies of treatment for Hypochondriacal Disorder.13

Implications
In conclusion, this study demonstrates that patients treated with CBT for Hypochondriacal Disorder have significantly reduced health anxiety 1 year after treatment completion and the results are maintained 10 years later.

As a result of the long follow-up period and the lack of a control group, the positive results cannot be attributed to the therapy alone and because one therapist treated all the patients this limits the generalizability of the findings. The results are, however, an indication that CBT has a long-lasting effect on Hypochondriacal Disorder.


More information: Kari-Elise Frøystad Veddegjærde et al. Long-term effect of cognitive–behavioural therapy in patients with Hypochondriacal Disorder, BJPsych Open (2020). DOI: 10.1192/bjo.2020.22

References

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