Copyright Q 1992 Pergamon Press plc ... and ~~epartment of Clinical Psychology, University of Groningen, Academic ~ospitff~, ~ostersinge~ 59,. 9713 EZ ...
~5-7967~92 $5.00+ 0.00 Copyright Q 1992Pergamon Press plc
Behav.Res. Ther. Vol. 30, No. 3, pp. 301-306,1992 Printed in Great Britain. All rights reserved
CASE HISTORIES Cognitive-behavioural
AND SHORTER
COMMUNICATIONS
approaches in the treatment of hypochondriasis: cross-over studies
six single case
SAKO VISSER’* and THEO K. BOUMAN* l~epartment of General Practice, University of Groningen, Antonius ~e~~ng~uan 4, 9713 A W Groningen and ~~epartment of Clinical Psychology, University of Groningen, Academic ~ospitff~, ~ostersinge~ 59, 9713 EZ Gron~ngen, The hIetherland~ (Received 5 September 1991) Summary-This study evaluates a cognitive and a behavioural treatment protocol for hypochondrical complaints. In a cross-over design, six patients with a primary diagnosis of hypochondriasis were treated. Three of them first received a block of behavioural therapy (exposure in viuo and response prevention), followed by a block of cognitive therapy. The other three patients were first treated with cognitive therapy followed by behavioural therapy. The results were promising: four patients made significant improvements. The behavioural therapy sessions appeared to account more often for improvement than did the cognitive sessions. The sequence of behavioural therapy followed by cognitive therapy tended to be more successful than the other way around. The results of these six case studies suggest that exposure in viva with response prevention and cognitive therapy may both be useful in the treatment of h~ochondriasis. A journal controlled study is recommended.
The hypochondriacal patient is convinced or anxious of suffering from a serious disease, which prompts him to frequently consult his general practitioner in search of reassurance. Disease related situations as well as physical strains are avoided. They are associated with, or might cause, symptoms which are interpreted as signs of the feared disease. Reassurance about health is obtained by asking relatives, the general practitioner and by demanding to be referred to medical specialists for a more sophisticated clinical examination. Many hypochondriacal patients have an impressive medical career of various clinical examinations and even surgical operations. Despite these circumstances they remain anxious. Throughout the years the definition of hypochondriasis has changed and up to now clinicians can be in doubt whether, and when, to make a positive diagnosis of hypochondriasis. Its current criteria according to the DSM-III-R (American Psychiatric Association, 1987) are presented in Table 1.The diagnosis of hypochondriasis is often associated with depression (Kenyon, 1964) or obsessive-compulsive complaints (Marks, 1978). In addition to the diagnostic ambiguity, treatment of hypochond~asis is often tedious, because of the patient’s somatic orientation. The patient often persists in avoidance of threatening stimuli and reassurance seeking. A longer duration of the complaints is positively related to a poor prognosis (Kellner, 1986). The behavioural literature on treatment of hypochond~asis describes primarily single case and uncontrolled group studies. Up to now several behavioural interventions for the treatment of hypochondriasis and related conditions, in particular ‘cardiac neurosis’, have been proposed. Reports on case studies or uncontrolled group designs evaluate systematic desensitization (Rifkin, 1968; Floru, 1973), thought stopping (Kumar & Wilkinson, 1971), exposure in uivo (Furst & Cooper, 1970; O’Donnell, 1985), applied relaxation (Johansson & &t, 1981), and exposure with response prevention (Warwick 8c Marks, 1988). In a controlled study on cardiac phobia, Fiegenbaum (1986) found no difference between exposure therapy as such and exposure along with problem solving group therapy. The behavioural technique of exposure in viva has proven to be effective for the anxiety disorders (Emmelkamp, 1982; Marks, 1987). In view of the fact that hypochondriacs show high anxiety and strong avoidance behaviour as well, exposure too may be a useful intervention for these patients. Besides, response prevention has proven to be effective in the treatment of obsessive compulsive disorders (Emmelkamp, 1982; Marks, 1987). Since many hypochondriacs are compulsively seeking reassurance, response prevention can be a promising intervention in their treatment. This has actually been suggested by several authors (Marks, 1987; Warwick & Salkovskis, 1986). Attention has recently shifted to cognitive-behavioural approach. Warwick and Salkovskis (1990) describe a cognitive formulation of hypochond~asis with the catastrophic misinte~retation of bodily sensations as a ~ntrepoint. Reassurance seeking is seen as a parallel of the anxiety reduction strategies in obsessive compulsive patients. Up to now only uncontroll~ studies testing this paradigm have been published (e.g. Salakovskis & Warwick, 1986). Some authors describe their treatment approach without empirical support (e.g. Barsky, Geringer & Wool, 1988). Since cognitive therapy has proved to be effective in the treatment of obsessive compulsive disorders (Emmelkamp, Visser & Hoekstra, 1988) and the hypochondriac is seeking reassurance in a compulsive-like way it is worthwhile investigating the potency of cognitive therapy in the treatment of hypochondriasis. In the present study the treatment of six patients with a primary diagnosis of hypochondriasis according to the DSM-III-R criteria is described. The goal of this study was to evaluate the effectiveness of a behavioural and a cognitive treatment protocol in a cross-over design. *Author for correspondence.
302
CASE HlSTORIES AND
SHORTER COMMWNICATIONS
Table 1. DSM-III-R criteria for hypochondriasis (American Psychiatric Association. 1987; p. 261, code 300.70) (A}
Pre~upation with the fear of having, or the belief that one has, a serious disease, based on the persan’s interpretation of physical signs or sensations as evidence of physical illness.
(B)
Appropriate physical evaluation does not support the diagnosis of any physical disorder that can acxount for the physical signs or sensations or the person’s unwarranted i~te~retatioo of them, and the symptoms in (A) are not just symptoms of panic attacks.
(C)
The fear of having, or belief that one has, a disease persists despite medical reassurance. (D) Duration of the disturbance is at least 6 months. (F) The belief under (A) is not of delusional intensity, as in Delusional Disorder, Somat~ Type (i.e. the person can acknowledge the possibility that his or her fear of having, of belief that he or she has. a serious disease is tlnfounded~)
METHOD
The six patients (four women and two men) had been referred by their general practitioner to our treatment facilities at the Department of Clinical Psychology. All patients complained of being excessively preoccupied with health related worries and all of them ful~li~d the DSM-III-R criteria of hypochondrias~s. The mean duration of their hypochondriacal complaints was 6.7 yr, ranging from 7 months to I2 yr, their man age was 34 yr (ranging from 24 to 47 yr). A number of characteristics of each patient are described in Table 2. Two treatment blocks were compared in a cross-over design: a behavioural one and a cognitive one. The treatments covered twelve I-hr sessions, five of which were devoted to exposure in z&o and five to cognitive interventions. In the first session a further assessment was carried out, while the tinai session consisted of a recapitulation and a discussion of the treatment as a whole. For three patients therapy started with exposure with response prevention, followed by cognitive interventions. For the other three patients the order was reversed. The therapies were conducted by three experienced clinical psychologists. Before and after treatment a 4 week no-treatment block was incIuded to get a stable baseline. (A) In the exposure in rive with response prevention sessions a hierarchy ofspecifichypochondriacal avoidance behaviour was constructed, including avoidance of situations (hospitals, physical exertion, reading information leaflets, programs on television) or actions (strains, sports, talking about diseases). The compulsively reassurance-seeking actions (checking own body, visits to general practitioner, asking partner, checking in medical boaks) were also included in this hierarchy. Each session was followed by homework assignments in which steps from the hierarchy were practised. (B) Cognitive therapy fallowed the guidelines provided by Beck and Emery (I985) and included monitoring of fear-providing cognitions with a credibility score for each cognition. The next step was a Socratic discussion of the cognitions. helping the patient to formulate alternative explanations of the somatic sensations and eventual replacement by more adequate, functional, non-catastrophic cognitions. Homework assignments consisted of recording and challenging catastrophic thoughts by using monitoring sheets. No behavioural assignments were given, On five occasions several self-report questionnaires were administered: at the intake, at the start of the treatment, halfway treatment, after the first treatment block at the end of treatment at 3-months follow-up. The Illness Attitude Scale (IAS: Kellner, 1987) consists of 28 items, and is divided into 9 three-item subscales (WI: Worries about Illness, CP: Concern about Pain, HH: Health Habits, HB: Hypochondriacal Beliefs, TH: Thanatophobia, DP: Disease Phobia, BP: Bodily Preoccupation, TE: Treatment Experience, ES: Erects of Symptoms). Each item is scored from 0 to 4, and since all scales are equal in length, scale scores range from 0 to 12. The IAS scales particular relevant as outcome variables in our study are the scales on Worries about Illness (WI), IIy~achondriacaI Beliefs (HB). Disease Phobia (DP) and Bodily preoccupation (BP). Beck’s Depression Inventory (BDI: Beck, Rush, Shaw & Emery, 1979) is probably the most frequently used self-report depression scale. It consists of 21 groups of four statements describing depressive symptoms. from which the patient has to choose the most appropriate (item scores range from 0 to 3). The sumscore may range from 0 to 63; empirically, a mean of about 20 is generally found in psychiatric patients. The Maudsley Obsessive Compulsive Inventory (MOCI; Rachman & Hogdson, 1977) consists of 30 dichotomously scored items. The MOCI measures the amount of obsessive-compulsive behaviours; pure obsessions excepted. Although the MOCI consists of five subscales we only use the sumscore in this study. The Symptom Check List @CL-90; Derogatis, Lipman & Cov. 1973; Dutch authorized translation and adaptation by Arrindell t Ettema, 1986) consists of 90 items referring to a vast array ofpsychopathology.Dutch factorial studies revealed 8 subscaies and a total score: Agoraphobia (range 7-35). Anxiety (range lo-SO), Depression (range 16GIO),Somatization (range 12-60), Interpersonal Sensitivity (range 18-90), insufficiency of thought and action (range 994S), HostiIity (range 6630), Sleeping problems (range 3-15) and a total score referred to as Psychoneuroticism (range 90-450).
RESULTS Table 2 presents an overview of the scores of the six cases. The scale scores for the six patients show differences at intake. The patients 2 and 6 were at intake highly depressed, whereas patient 1 was mildly depressed: patients 3-5 were only slightly depressed. Remarkable differences among the
216
148
somatization hostility
total score
146
296
29 33
4
3 9 IO
12 8
146
266
26 29
3
4 8 9
12 7
162
266
31 32
2
5 8 10
IO 6
242
24 13
26 55
s
12 12 38
12 9
235
21 10
25 55
5
II 12 32
12 8
183
16 8
23 35
4
7 7 20
9 6
143
14 9
16 21
4
7 8 9
8 3
IS2
16 8
17 31
4
8 8 10
9 3
F
133
216
15 27
3
4 IO 15
IO 110
132
216
13 29
5
6 7 18
8
166
387
26 34
0
0 8 !S
8
97
14 7
11 IS
I1
0 2 8
5 0
cognitive-behaviour B PO I Pr
cancer, aids 1Syr
female 3syr
108
12 6
II 16
0 4 10
5 0
F
108
I?6
16 22
2
5 8 12
6 4
I
107
16 6
17 21
3
2 4 10
4 0
165
24 9
33 34
7
I2 12 8
12 8
I
134
16 6
27 29
5
12 IO 6
12 6
I
0 0 0
0 0
PO
behaviour Pr B
cognitive Pr B F
cancer, aids, cardiac I months
cardiac I2 months
Case 5 male 24 yr
PO
over time
male 21 yr
Case 4
results for the six cases-studies
case 3
IAS scales: WI, Worries about illness; HB, hypochondriacal beliefs; DPL, Disease Phobia; BP, Bodily preoccupations. I = intake; Pr = pm-treatment; B = between treatment blocks; PO = post-treatment; F = follow-up.
160
236
4
25 33
4
4 9 17
27 32
4 9 18
DP BP Depression
12 7
OCD (MOCI) SCL-90 anxiety depression
10 6
(BDI)
F
behaviour-cognitive I Pr B PO
cognitive-behaviour B PO I Pr
female 35 yr
Case2
Table 2. An overview and the questionnaire
cardiac, Alzheimer 12yr
female 47 yr
I
cancer 16 months
WI HB
IAS
Therapy Measurement
Feared disease Duration
Age
sex
Case
F
211
28 9
37 51
9
4 IO 39
12 7
197
248
34 38
6
4 II 25
12 8
126
15 7
17 21
5
0 4 3
8 2
119
13 7
15 18
4
0 3 3
8 2
behaviour-cognitive B PO 1 Pr
Gi”ciY 1Oyr
female 35 yr
Case 6
124
15 7
17 17
4
0 4 3
8 2
F
B
2
“n !
8
B 2 $:
$
6 t-T 8 I
sl I
304
CASE
IAS:
Disease
HISTORIES
AND
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COMMUNICATIONS
phobia
IAS:
Hypochondrlacal
beliefs
12
0 b6 ;;
R +. I../
Intake
’
--
Case 3 cog-kh
““+.‘.’
4 cognltlve
! \
Pre
, \
+
Between
post
case
0 Intake Pre
FOIIOW
Fig. 1. Scores in time on two Illness Attitude
Between
.l
A
Post
FOllOW
subscales.
patients at intake were also found with regard to the factors of the Illness Attitude Scale. Except from patient 4, they all scored high on the factors ‘Worries about Illness’ (WI) and ‘Bodily Preoccupation’ (BP). Patients 2 and 5 too scored high on the other factors. To illustrate the course of treatment, Fig. 1 gives for each patient scores on the Illness Attitude Scale for the factors Hypochondriacal Beliefs (HB) and Disease Phobia (DP). The differences among patients at intake become apparent. as well as a change in scores for most of the patients after the treatment blocks. To assess the clinical significance of the improvement achieved, the scores on the four IAS scales were converted into a percentage of change from the intake-scores. The degree of improvement was defined as follows (Foa, Doppelt, Turner & Latimer. 1983; Visser. Hoekstra & Emmelkamp, 1990): (a) much improved: those who improved 70% or more compared (b) improved: those who recorded gains of 31-70% and (c) not improved: those who improved only ~30%. The degree
of improvement
for each patient
is reported
with the intake-scores:
in the description
of the six case-studies.
The siu case-s/udies Patient No. I did not improve at all. Apart from the hypochondriacal belief of having cancer, this patient suffered from sleeping problems, which remained unchanged during therapy. Her over-all feeling at the end of therapy was that she did not make any progress, but felt a little less depressed. This is confirmed by the results on the questionnaires: she did not improve on any of the IAS-scales and showed some improvement on the depression inventory. Patient No. 2 suffered from a poly-symptomatic hypochondriasis concerning serious cardiac illness and Alzheimers’ disease. She made good progress in the first treatment block (exposure in uitw and response prevention); cognitive therapy, however, was less effective. She scored very high on the Illness Attitude Scale at the beginning of therapy. Although the progress has been good, there were still residual hypochondriacal complaints (i.e. worries about her heart) at 3-months follow-up. This patient had improved on all IAS-scales. Parienr NO. 3 also suffered from a poly-symptomatic hypochondriasis. The treatment was successful: during both cognitive therapy and behaviour therapy good progress was made, which persisted at follow-up. She had improved on the ‘Worries about Illness’ and ‘Bodily Preoccupations’ scales and much improved on the ‘Hypochondriacal Beliefs’ and ‘Disease Phobia’ scales. Purienr No. 4 is a special case. The therapy did not actually start. The patient felt that he was cured after two sessions only, so he stopped the therapy. Factors which could account for his seemingly quick progress could be: first, the short duration of the relatively mild complaints; secondly, the patient had taken up a new and interesting job in this period. The patient was very enthusiastic about the rationale of cognitive therapy after the therapist’s explanation, and felt that he could manage on his own. He was much improved on the Hypochondriacal Beliefs and Disease Phobia, and improved on the Worries about Illness and Bodily Preoccupations scales. Unfortunately no follow-up data are available. Pa/ient No. 5 received only one treatment block (exposure in ciao with response prevention), after which his hypochondriacal complaints had disappeared entirely, so he felt no need for further treatment. He had much improved on all the IAS-scales. This patient too had gambing problems (hypochondriasis was his primary complaint at the intake) for which he was treated in addition. The improvement on this hypochondriacal complaints was stable at follow-up 3 months after termination of treatment. Parirnf No. 6 was also treated successfully. She had rather serious hypochondriacal complaints and was very depressed at the intake. Hypochondriasis was her primary complaint and depression her secondary. Both complaints diminished during treatment. A major improvement was brought about during the first treatment block: exposure in vice with response prevention. Extensive reassurance seeking was one of the main features of her complaints, and quick progress was established by response prevention. The improvement remained during the cognitive treatment block and at follow-up. She had improved on the Worries about Illness and Bodily Preoccupations scales and much improved on the Hypochondriacal Beliefs and Disease Phobia. DISCUSSION
The results of this study should be viewed with some caution. First: of a mere six cases one was unsuitable to make any statements at issue are to be tested in larger controlled studies.
on therapy
outcome.
As a result, the hypotheses
CASE
HISTORIES
AND
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305
Secondly, all the hypochondriacal patients treated in this study were referred by a general practitioner. They represent a special group of hypochondriacs, i.e. those who are willing to look at their complaints from a psychotherapeutic point of view. Probably, they are more motivated than hypochondriacs who go on seeking reassurance in the medical circuit. Despite this seemingly stronger motivation, our clinical experience was that the treatment of hypochondriacs is rather complex. Their persistent avoidance behaviour and reassurance seeking, and the often obsessional features of fear-provoking thoughts are hard to change. However, the results of these six case studies are promising. Three patients had improved or much improved while one patient had improved, although she had still some residual hypochondriacal complaints at the end of therapy. So, in four cases the treatment may be called a success and only one patient did not improve. There were, however, no clear indications why the treatment in cases 3, 5, and 6 was more successful than in case 2, and why the treatment in case 1 was not successful at all. Neither the gravity of the complaints-as measured by the self-report questionnaires-had any influence on therapy results, nor had the poly- or mono-symptomatic character of hypochondriasis. Additional psychopathology, like depression or gambling, had no marked influence on therapy outcome as well. Since controlled studies on the treatment of hypochondriasis are not available it is impossible to compare our results with other research. Comparison with other case-studies is also problematic, because of the differences in the selection of patients, and the report and measurement of therapy outcome. Interesting in our data is that none of the patients had any obsessive-compulsive complaints as measured by the MOCI. Several authors compare the reassurance seeking rituals with the rituals in the obsessive-compulsive disorder (Marks, 1978; Warwick & Salkovskis, 1987). Anyhow, in our study hypochondriacs do not resemble unrecognized obsessive-compulsives. In view of the results of the separate treatment blocks, exposure in viuo with response prevention contributes more often to improvement (cases 2, 3, 5 and 6) than cognitive treatment (case 3). A limiting factor in generalizations is the use of a cross-over design. It is rather difficult to make statements about the effectiveness of the second therapy block without having an insight into the influence of the first treatment block (i.e. without knowledge of the impact of the carry-over effect). The cross-over design was chosen to see whether a different treatment block could possibly have an additional effect on therapy outcome after the first treatment block. No such effect was found in our study. Besides, we were interested in the order of treatment blocks and their effects on therapy outcome. A current tendency for exposure in uiuo with response prevention preceding cognitive therapy appears to be more successful than conversely. Summarizing, we can say that the results of the six case studies suggest that exposure in viva with response prevention and cognitive therapy may both be useful in the treatment of hypochondriasis. As stated above the results are based on a limited number of observations and should be tested as hypotheses within the context of a larger, controlled evaluation study. For that reason, the conception of well-controlled studies with a long-term follow-up on the treatment of hypochondriasis is desirable.
REFERENCES
American Psychiatric Association (1987). Diagnostic and srarisfical manual of mental disorders (3rd rev. edn). Washington, D.C.: American Psychiatric Association. Arrindell, W. A. & Ettema, J. H. M. (1986). XL-94 handleiding bij een mulfidomensionele psychopafhologie indicator. (XL-90, manual of a mulfidimensional indicator of psychopathology.) Lisse: Swets & Zeitlinger. Barsky, A. J., Geringer, E. & Wool, C. A. (1988). A cognitive educational treatment for hypochondriasis. General Hospital Psychiatry, IO, 3222327. Beck, A. T. & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books. Beck, A. T., Rush, A. J., Shaw, B. F. & Emery, G. (1979). Cognitive therapy of depression. Chichester: Wiley. Derogatis, L. R., Lipman, R. S. & Covi, L. (1973). SCL-90: An outpatient taring scale: Preliminary report. Psychopharmacological Bulletin, 9, 13328. Emmelkamp, P. M. G. (I 982). Phobic and obsessive-compulsive disorders: Theory, research and practice. New York: Plenum Press. Emmelkamp, P. M. G., Visser, S. & Hoekstra, R. J. (1988). Cognitive therapy vs exposure in uivo in the treatment of obsessive-compulsives. Cognitive Therapy and Research, 12, 1033144. Fiegenbaum, W. (1986). Longterm efficacy of exposure in viuo for cardiac phobia. In Hand, I. & Wittchen, H.-U. (Eds), Panic and phobias. Heidelberg: Springer. Floru, L. (1973). Verhaltenstherapeutische versuche durch systematische desensibihsierung. Psychiatrica Clinica, 6, 300-318. Foa, E. B., Doppelt, H. G., Turner, R. M. & Latimer, P. R. (1983). Success and failure in the behavioural treatment of obsessive-compulsives. Journal of Consulting and Clinical Psychology, 51, 287-297. Furst, J. B. & Cooper, A. (1970). Combined use of imaginal and interoceptive stimuli in densensitizing fear of heart attacks. Journal of Behaviour Therapy and Experimental Psychiatry, I, 57-61. Johansson, J. & t)st, L. G. (1981). Applied relaxation in treatment of “cardiac neurosis”: A systematic case study. Psychological Reports, 48, 463-468. Kellner, R. (1986). Somatizalion and hypochondriasis. New York: Praeger. Kellner, R. (1987). Abridged manual of the illness attitude scales. Albuquerque, N.M.: Department of Psychiatry, Kenyon, F. E. (1964). Hypochondriasis: A clinical study. British Journal of Psychiatry, fl0, 478-488. Kumar, K. & Wilkinson, J. C. M. (1971). Thought stopping: a useful technique in phobias of internal stimuli. British Journal of Psychiafry, 119, 305-307. Marks, I. M. (1978). Living with fear. New York: McGraw-Hill. Marks, I. M. (1987). Fears, phobias, and rifuals. Oxford: Oxford University Press. O’Donnell, J. M. (1978). Implosive therapy with hypnosis in the treatment of cancer phobia: A case report. Psychotherapy, Theory, Research and Practice, 15, 181-183. Rachman, S. & Hodgson, R. (1977). Obsessional-compulsive complaints. Behaoiour Research and Therapy, IS, 389-395. Rifkin, B. G. (1968). The treatment of cardiac neurosis using systematic desensitization. Behauiour Research and Therapy, 6, 239-240.
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Salkovskis, P. M. & Warwick, H. M. C. (1986). Morbid preoccupations, health anxiety and reassurance: A cognitivebehavioural approach to hypochondriasis. Behavioural Research and Therapy, 24, 597-602. Visser, S., Hoekstra, R. J. & Emmelkamp, P. M. G. (1990). Follow-up study on the behavioural treatment of obsessive compulsive disorders. In Fiegenbaum, W., Florin, I., Elers, A. & Margraf, J. (Eds), Zukunfrperspecfiven der clinischen psychologie. Miinchen: Springer. Warwick, H. M. C. & Marks, I. M. (1988). Behavioural treatment of Illness Phobia and Hypochondriasis. British Journal of Psychiatry, I52, 239-241. Warwick, H. M. C. & Salkovskis, P. M. (1987). Hypochondria& In Scott, Williams & Beck (Eds), Cognitive therapy: A clinical casebook. London: Croom Helm. Warwick, H. M. C. & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and Therapy, 28, 105-l 17.
