Julia M.B. Neng

The restrictive concept of good health in patients with hypochondriasis

The restrictive concept of good health and the misinterpretation of bodily symptoms as a sign of illness are considered in the DSM and in well-established cognitive models as central characteristics of hypochondriasis. However, until now it has not been satisfactorily resolved whether this tendency is unique for hypochondriasis. In the current study a modified card sorting technique was used to investigate the extent to which bodily complaints were seen as compatible with a state of good health. We found that patients with hypochondriasis (n = 45) showed a more restrictive concept of good health than anxiety patients (n = 45) and healthy controls (n = 45). Those differences were only observable when a concrete evaluation of own bodily symptoms was carried out in comparison to a more general evaluation of symptoms. The misinterpretation of bodily symptoms demonstrates to be a highly specific characteristic of hypochondriasis.

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

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 (Hedgess g = 1.01-1.11) and ET (Hedgess 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 the change of dysfunctional cognitions. These findings are relevant to the conceptualization and psychotherapeutic treatment of hypochondriasis and health anxiety.

Attribution of Somatic Symptoms in Hypochondriasis

The misinterpretation of bodily symptoms as an indicator of a serious illness is a key feature of the criteria and the cognitive-behavioural models of hypochondriasis. Previous research suggests that individuals suffering from health anxiety endorse attributions of physical disease, whereas persons with elevated general anxiety have the tendency to attribute psychological causes to their symptoms. However, whether a somatic attribution style is specific to patients with hypochondriasis, as opposed to those with anxiety disorders, has not yet been investigated and is therefore part of the present study. Fifty patients with hypochondriasis, 50 patients with a primary anxiety disorder and 50 healthy participants were presented with nine common bodily sensations and had to spontaneously attribute possible causes to the symptoms. Patients with hypochondriasis differed from patients with anxiety disorders and healthy controls in giving significantly fewer normalizing explanations, but attributing more often in terms of moderate or serious diseases. Patients with anxiety disorders also made significantly fewer normalizing attributions and more somatic attributions to a severe illness than healthy controls. There were no differences between the groups in the frequency of psychological attributions and somatic attributions concerning mild diseases. The present study demonstrates that hypochondriasis is associated with a disorder-specific attribution style connecting somatic symptoms primarily with moderate and serious diseases. By contrast, normalizing attributions are largely omitted from consideration by patients with hypochondriasis. The findings conform with the cognitive conception of hypochondriasis and support the strategy of modifying symptom attributions, as practiced in cognitive-behavioural therapy.

The German Version of the H-YBOCS for the Assessment of Hypochondriacal Cognitions and Behaviors: Development, Reliability and Validity

BackgroundClinician-administered interviews are essential for assessing the efficacy of treatment studies and constitute an important instrument for clinical practice. Recently, the Yale–Brown Obsessive Compulsive Scale was adapted for the dimensional assessment of hypochondriacal characteristics (H-YBOCS) and yielded promising results.PurposeThis study aimed to develop and validate a German version of the H-YBOCS.MethodAltogether, 101 patients with hypochondriasis and 49 patients with anxiety disorders were diagnosed using the German version of the H-YBOCS. Well-established questionnaires for assessing hypochondriacal characteristics and the general psychopathology were administered as well.ResultsExploratory and confirmatory factor analyses suggested a three-factor structure for the German version of the H-YBOCS (cognitive factor, behavioral factor, and insight factor). The current version of H-YBOCS demonstrated high internal consistency (α = 0.93) and inter-rater reliability (ICC = .97). Convergent and discriminant validity were also confirmed by high correlations with questionnaires such as the Illness Attitudes Scales (r = 0.81) and non-significant correlations with the Brief Symptom Inventory (r = 0.12). The H-YBOCS discriminated between patients with hypochondriasis and those with anxiety disorder, with high sensitivity (0.94) and specificity (0.78).ConclusionThe German version of the H-YBOCS proved to be a highly effective interview instrument for the dimensional assessment of hypochondriacal characteristics and therefore constitutes an important contribution to scientific research and clinical practice.

Exposure therapy changes dysfunctional evaluations of somatic symptoms in patients with hypochondriasis (health anxiety). A randomized controlled trial.

Dysfunctional evaluations of somatic symptoms are considered a central factor in maintaining hypochondriasis. The aim of the current study was to investigate whether exposure therapy (ET) without cognitive restructuring is sufficient to change dysfunctional evaluations of somatic symptoms. The current study was based on a randomized controlled trial and compared patients with hypochondriasis (N=73) receiving ET or cognitive therapy (CT) to a wait list (WL) control group. In both the ET and CT groups, dysfunctional symptom evaluations changed significantly compared with the WL group. No differences between the ET and CT groups emerged. The relationship between the treatment condition (active treatment vs. WL) and reductions in health anxiety was mediated by changes in somatic symptom evaluations only in a specific card sorting procedure. We conclude that addressing dysfunctional symptom evaluations is a necessary precondition for the effective treatment of hypochondriasis. However, the results indicate that ET and CT appear to change those processes to a similar degree.

Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis)

The role of treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) is rarely investigated in psychotherapeutic treatment for health anxiety. This study aimed to investigate the role of the assessment perspective for the evaluation of treatment delivery factors and their relevance for treatment outcome. Therapist adherence, therapist competence, and therapeutic alliance were evaluated by independent raters, therapists, patients, and supervisors in 68 treatments. Patients with severe health anxiety (hypochondriasis) were treated with cognitive therapy or exposure therapy. Treatment outcome was assessed with a standardized interview by independent diagnosticians. A multitrait-multimethod analysis revealed a large effect for the assessment perspective of therapist adherence, therapist competence, and therapeutic alliance. The rater perspective was the most important for the prediction of treatment outcome. Therapeutic alliance and therapist competence accounted for 6% of the variance of treatment outcome while therapist adherence was not associated with treatment outcome. Therapist competence was only indirectly associated with treatment outcome, mediated by therapeutic alliance. Both therapeutic alliance and therapist competence demonstrated to be important treatment delivery factors in psychotherapy for health anxiety. A stronger consideration of those processes during psychotherapy for health anxiety might be able to improve psychotherapy outcome.

Previous experiences with illness and traumatic experiences: a specific risk factor for hypochondriasis?

BACKGROUND Previous experiences with illness and traumatic experiences are considered as important risk factors for the development of health anxiety and hypochondriasis. However, empirical research is insufficient and lacks adequate comparison groups. OBJECTIVE Therefore, we sought to determine whether experiences with illness and traumatic experiences are really specific risk factors for hypochondriasis. METHOD In the current study, patients with the diagnosis of hypochondriasis (n = 80), patients with a primary anxiety disorder (n = 80), and healthy controls (n = 83) were investigated regarding their previous experiences with illness (self and other) and traumatic childhood experiences. RESULTS We found that patients with hypochondriasis reported a higher level of experience with illness and with traumatic childhood experiences than healthy controls. However, no differences were found between patients with hypochondriasis and those with an anxiety disorder, regarding their level of experience with illness and traumatic experiences. CONCLUSIONS Previous experiences with illness and traumatic childhood experiences did not prove to be specific risk factors for the development of hypochondriasis. The importance of both experiences with illness and traumatic experiences as risk factors, as considered in the Diagnostic and Statistical Manual and in established cognitive-behavioral models, does not seem to be supported empirically. Further research should therefore also consider other potential risk factors discussed in the literature.

The Effects of Bug-in-the-Eye Supervision on Therapeutic Alliance and Therapist Competence in Cognitive-Behavioural Therapy: A Randomized Controlled Trial.

Live supervision enables a supervisor to have direct insight into the psychotherapeutic process and allows him or her to provide immediate feedback to the trainee. Therefore, live supervision might be superior to traditional supervisory formats that only allow for the provision of delayed feedback. When considering the different live supervision formats, bug-in-the-eye (BITE) supervision is particularly promising because of its improved and less invasive procedure. The current study compared the efficacy of BITE supervision with that of delayed video-based (DVB) supervision. In the present study, 23 therapists were randomly assigned to either the BITE supervision or DVB supervision groups. The participants were psychotherapy trainees who treated 42 patients (19 under BITE supervision and 23 under DVB supervision) over 25 sessions of cognitive-behavioural therapy. Two independent raters blind to the treatment conditions evaluated therapeutic alliance and therapist competence based on 195 videotapes. Therapeutic alliance was significantly stronger among the treatments conducted under BITE supervision than those conducted under DVB supervision. Moreover, a higher level of therapeutic competence was found in the BITE condition than in the DVB condition. However, no differences between supervision conditions were found when the results were controlled for the level of therapeutic alliance and therapist competence demonstrated in the first session. No differences were observed between the supervision conditions with respect to patient outcomes. There is evidence that BITE supervision is able to improve therapeutic alliance and therapist competence. However, these findings should be interpreted with caution because possible pre-treatment differences between therapists might explain the superiority of BITE supervision. Copyright

Epidemiology of Hypochondriasis and Health Anxiety: Comparison of Different Diagnostic Criteria

This review addresses the prevalence of hypochondriasis and less restrictive subtypes of hypochondriacal phenomena (abridged hypochondriasis and health anxiety). Altogether, 55 papers based on 47 independent samples reporting prevalence rates of hypochondriasis, abridged hypochondriasis, and health anxiety were taken into account. Investigations of the general population, general medical samples (e.g., primary care) and specific clinical samples (e.g., cancer patients) were included in the present review. In general populations a weighted prevalence of 0.40% was found for hypochondriasis (range 0.0-4.5%) and a weighted prevalence of 1.00% (0.6-2.0%) was found for abridged hypochondriasis. Health anxiety was frequently reported in general populations with a wide range (2.1-13.1%). In general medical samples a weighted prevalence rate of 2.95% (range 0.3-8.5%) was found for hypochondriasis. Abridged hypochondriasis was only reported in one study; however, the prevalence of abridged hypochondriasis was three times higher than the full diagnostic criteria of hypochondriasis. In specific clinical samples (e.g., cancer patients, psychiatric outpatients) hypochondriasis and health anxiety were frequently reported as well. Comparisons of persons with the full hypochondriasis diagnosis and abridged hypochondriasis show large similarities regarding psychopathological characteristics and clinical impairment, which underline the importance of a less restrictive definition of hypochondriasis considered in DSM-5. Findings regarding potential risk factors were very inconsistent and no clear risk factors could be identified. The high prevalence of hypochondriasis in medical settings should be addressed in the future with effective screening instruments in order to optimize treatment strategies for patients with hypochondriasis and persons with elevated health anxiety.

Implicit affective evaluation bias in hypochondriasis: Findings from the Affect Misattribution Procedure

Cognitive theories of hypochondriasis (HYP) suggest that catastrophic misinterpretations of benign body sensations are a core feature for the maintenance of the disorder. There is tentative support from an analog sample that the interpretation of illness-related information also involves an implicit affective component. This is the first study to examine this negative affective evaluation bias implicitly in patients with HYP. An adapted version of the Affect Misattribution Procedure (AMP) with illness, symptom and neutral primes was used in 80 patients with HYP, and compared to 83 patients with an anxiety disorder (AD), as well as 90 healthy controls (CG). The HYP group showed significantly more negative affective reactions in illness prime trials, compared to both control groups, as well as more negative implicit evaluations on symptom prime trials, compared to the CG. Significant inverse relationships were observed only between the implicit evaluations of illness words and health anxiety questionnaires. Thus, an implicit negative affective evaluation bias of serious illnesses rather than symptoms is a unique feature of HYP.