Mental health articles

Psychological treatment

Psychological treatment for hypochondriasis can be difficult, particularly where individuals hold a strong belief in their having a physical disease. One way this has been addressed is through the use of a variety of CBT interventions, including:

Behavioural hypothesis testing: this can involve working with a client to investigate the reality of their symptoms. If someone has a fear of a muscle-wasting disease, for example, they may predict they would become extremely weak if they engage in even light exercise. With some encouragement, this hypothesis can be tested – and hopefully found to be inaccurate.

Reducing checking and medical consultation: in order to reduce safety behaviours in general, and use of medical support in particular, the client may reduce checking behaviour and medical consultations – or delay them. This is similar to the approach taken in obsessivecompulsive disorder and phobias: that is, exposure plus response prevention. They may also develop a realistic strategy for when to seek medical help.

Cognitive challenge: this involves techniques to counter some of the catastrophic thoughts that an individual may have about their symptoms. Thus, fear that one has a serious heart problem may be based on the experience of chest discomfort, heart missing a beat, and breathlessness. These experiences may be contextualized and made less threatening by reframing:

– ‘Most heart beats change rhythm from minute to minute.’

– ‘It’s normal to become breathless following exertion

– especially if you are unfi t.’

– ‘I’ve had these symptoms before, and although they made me worried, they did not lead to any problems.’

A number of studies have now shown cognitive behavioural interventions based on the Salkovskis model to be effective when compared with usual care. Barsky and Ahern (2004), for example, found benefi ts following a six-session CBT intervention including lower levels of hypochondriacal symptoms, beliefs and health-related anxiety at 6- and 12-month follow-up compared to a no treatment control group. Clark et al. (1998) compared their hypochondriasis treatment programme with a non-specifi c CBT intervention which targeted stress-related cognitions and emotions but not those specifi cally related to health concerns. Comparisons with a waiting list control group showed both treatments were more effective than no therapy. Initially, the interventions had specifi c benefi ts: cognitive therapy for hypochondriasis was more effective than CBT stress management on measures of hypochondriasis, but not on measures of general mood disturbance. However, one year after treatment, both interventions appeared equally effective on all measures. A very different approach was adopted by Papageorgiou and Wells (1998), who examined the effectiveness of training people with hypochondriasis to distract away from their worrying thoughts. In a series of three case reports, this resulted in improvements both in mood and in illness-related thoughts and behaviours lasting at least six months following treatment. Sørensen et al. (2010) compared Salkovskis’s CBT intervention augmented with the use of mindfulness and group therapy sessions with brief psychodynamic therapy and a waiting list control condition. By six-month follow-up, the augmented CBT intervention proved more effective than the psychodynamic one, which differed little from the control condition. By twelve-month follow up, these differences had reduced, but remained significant.

Pharmacological treatment

Until the late 1980s, the general consensus among clinicians was that pharmacotherapy would not benefi t people who experienced hypochondriasis. However, the similarities between hypochondriasis and obsessive-compulsive disorder have led to the use of SSRIs in an attempt to treat it, with some success – although large trials of their effectiveness are still lacking. In one study, Fallon et al. (2008) reported a small placebo-controlled trial of fl uoxetine and found signifi cant benefi ts during the 24 weeks in which patients were receiving the drug. Unfortunately, they were not able to report outcomes following discontinuation of the drug. In a study comparing psychological and pharmacological treatments, Greeven et al. (2007) reported a greater response to cognitive behavioural intervention than medication. Using an intention to treat analysis, they found that after 16 weeks treatment, 45 per cent of people in the psychological group achieved signifi cant reductions in symptoms, compared with 30 per cent of those treated with paroxetine (an SSRI) and 14 per cent given placebo. Of those to complete treatment, the equivalent percentages were 54, 38 and 12 per cent respectively.

Tags: hypochondriasis, treatment