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Fineberg NA, Pellegrini L, Clarke A, Perera U, Drummond LM, Albert U, Laws KR. Meta-analysis of cognitive behaviour therapy and selective serotonin reuptake inhibitors for the treatment of hypochondriasis: Implications for trial design. Compr Psychiatry 2022; 118:152334. [PMID: 36007340 DOI: 10.1016/j.comppsych.2022.152334] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Classification of hypochondriasis as an obsessive-compulsive and related disorder in the International Classification of Diseases 11th Revision (ICD-11) has generated new heuristics for treatment of this common, chronic and disabling disorder. Standard treatment involves cognitive behaviour therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs), but no meta-analysis has so far considered hypochondriasis as a structured diagnosis or assessed the role of medication. A clearer understanding of the relative effectiveness of these interventions and identification of clinically relevant factors moderating the treatment response is needed for clinical guideline development. METHODS The current systematic review and meta-analysis of interventions for hypochondriasis was preregistered on PROSPERO (CRD42020185768) and follows PRISMA guidelines. We searched MEDLINE, PsycINFO, and Cochrane Library databases until July 2021 for randomized controlled trials (RCTs) of interventions for patients diagnosed with hypochondriasis (or historical diagnostic equivalents). We assessed aspects of study quality using: the CONSORT Checklist for evaluation of RCTs, the Cochrane Risk of Bias 2 tool, researcher allegiance and treatment fidelity. The primary outcome was improvement in hypochondriasis symptoms, comparing intervention and control groups at trial endpoint. Moderator variables were assessed using subgroup and meta-regression analyses. RESULTS Searches identified 13 randomised controlled trials (RCTs) (N = 1405); 12 included CBT (N = 1212) and three included SSRI (N = 193) arms as the experimental intervention. Random effects meta-analysis yielded a moderate-to-large effect size for CBT versus all controls (g = -0.70 [95% CI -0.99 to -0.41], k = 18, I2 = 81.1%). Funnel plot asymmetry indicated possible publication bias and two potentially missing trials, reducing the effect size (g = -0.60 [95% CI -0.88 to -0.32]). Subgroup analysis showed that choice of control significantly moderated effect size, with those in CBT vs. wait-list (g = -1.32 [95% CI -1.75 to -0.90], k = 7, I2 = 0%) being double those of CBT vs. psychological or pharmacological placebo controls (g = -0.58 [95% CI -0.95 to -0.22], k = 7, I2 = 82%). Analysis of studies directly comparing CBT and SSRIs found a numerical, but not statistical advantage for SSRIs (g = 0.21 [95% CI -0.46 to 0.87], k = 2, I2 = 58.34%) and a modest effect size emerged for SSRIs vs. pill placebo (g = -0.29 [95% CI -0.57 to -0.01], k = 3, I2 = 0%). Most studies (11/13) were rated as high on potential researcher allegiance bias in favour of CBT. Meta-regressions revealed that effect sizes were larger in younger participants, and smaller in better quality and more recent RCTs and those with greater CBT fidelity. CONCLUSION CBT and SSRIs are effective in the acute treatment of hypochondriasis, with some indication that intervention at a younger age produces better outcomes for CBT. In the case of CBT, effect sizes appear to have been significantly inflated by the use of wait list controls, and researcher allegiance bias. We recommend that a definitive, adequately controlled trial, designed with respect to the methodological issues raised in this meta-analysis, is needed to determine the magnitude effects for CBT and SSRIs with confidence and the long-term effect of treatments, to inform mental health service provision for this overlooked patient group.
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Affiliation(s)
- Naomi A Fineberg
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom; Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, United Kingdom; University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Luca Pellegrini
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom; Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, United Kingdom; Centre for Psychedelic Research, Imperial College London, London, United Kingdom.
| | - Aaron Clarke
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Uday Perera
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, United Kingdom
| | - Lynne M Drummond
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom; South West London and St George's Mental Health NHS Trust, London, United Kingdom
| | - Umberto Albert
- Department of Medicine, Surgery and Health Sciences, UCO Clinica Psichiatrica, University of Trieste, Trieste, Italy
| | - Keith R Laws
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Hoffmann D, Rask CU, Hedman-Lagerlöf E, Jensen JS, Frostholm L. Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial. Psychol Med 2021; 51:2685-2695. [PMID: 32404226 PMCID: PMC8579157 DOI: 10.1017/s0033291720001312] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 04/06/2020] [Accepted: 04/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Health anxiety is common, disabling and costly due to patients' extensive use of health care services. Internet-delivered treatment may overcome barriers of accessibility to specialized treatment. We aimed to evaluate the efficacy of internet-delivered acceptance and commitment therapy (iACT). METHODS A randomized, controlled trial of iACT versus an internet-delivered discussion forum (iFORUM), performed in a Danish university hospital setting. Patients self-referred and underwent video-diagnostic assessment. Eligible patients (≥18 years) with health anxiety were randomized to 12 weeks of intervention. The randomization was blinded for the assessor. The primary outcome was between-group unadjusted mean differences in health anxiety symptoms measured by the Whiteley-7 Index (WI-7, range 0-100) from baseline to 6-month follow-up (6-MFU) using intention to treat and a linear mixed model. The study is registered at clinicaltrials.gov, number NCT02735434. RESULTS A total of 151 patients self-referred, and 101 patients were randomized to iACT (n = 53) or iFORUM (n = 48). A mean difference in change over time of 19.0 points [95% confidence interval (CI) 10.8-27.2, p < 0.001] was shown on the WI-7, and a large standardized effect size of d = 0.80 (95% CI 0.38-1.23) at 6-MFU. The number needed to treat was 2.8 (95% CI 1.8-6.1, p < 0.001), and twice as many patients in iACT were no longer clinical cases (35% v. 16%; risk ratio 2.17, 95% CI 1.00-4.70, p = 0.050). Adverse events were few and insignificant. CONCLUSIONS iACT for health anxiety led to sustained effects at 6-MFU. The study contributes to the development of easily accessible treatment options and deserves wider application.
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Affiliation(s)
- Ditte Hoffmann
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Noerrebrogade 44, bldg. 2C, 1, 8000Aarhus C, Denmark
| | - Charlotte Ulrikka Rask
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 175, ent. K, 8200Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200, Aarhus, Denmark
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 5, 171 77Stockholm, Sweden
| | - Jens Søndergaard Jensen
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Noerrebrogade 44, bldg. 2C, 1, 8000Aarhus C, Denmark
| | - Lisbeth Frostholm
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Noerrebrogade 44, bldg. 2C, 1, 8000Aarhus C, Denmark
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Fordham B, Sugavanam T, Edwards K, Hemming K, Howick J, Copsey B, Lee H, Kaidesoja M, Kirtley S, Hopewell S, das Nair R, Howard R, Stallard P, Hamer-Hunt J, Cooper Z, Lamb SE. Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis. Health Technol Assess 2021; 25:1-378. [PMID: 33629950 PMCID: PMC7957459 DOI: 10.3310/hta25090] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. OBJECTIVES This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. DATA SOURCES The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. REVIEW METHODS Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. RESULTS A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. LIMITATIONS Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. CONCLUSION Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. FUTURE WORK Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. STUDY REGISTRATION This study is registered as PROSPERO CRD42017078690. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thavapriya Sugavanam
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Katherine Edwards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Bethan Copsey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Milla Kaidesoja
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Shona Kirtley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roshan das Nair
- Department of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | | | | | - Zafra Cooper
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Menon V, Kar SK, Tripathi A, Nebhinani N, Varadharajan N. Cyberchondria: conceptual relation with health anxiety, assessment, management and prevention. Asian J Psychiatr 2020; 53:102225. [PMID: 32585634 DOI: 10.1016/j.ajp.2020.102225] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/06/2020] [Accepted: 06/11/2020] [Indexed: 01/25/2023]
Abstract
There is a need to synthesize available information on the emerging construct of cyberchondria to guide evidence informed practice. With this in mind, electronic search of databases including MEDLINE via PubMed, Cochrane Library, ScienceDirect and Google scholar were carried out from inception till March 2020 to identify relevant English language peer reviewed articles related to cyberchondria. Generated abstracts were grouped according to their thematic focus and summarized. A total of 49 articles were reviewed. Articles directly evaluating cyberchondria were very few and most of the treatment evidence was extrapolated from trials on health anxiety. Cyberchondria appears to be a phenomenologically overlapping entity with, yet distinguishable from, health anxiety and there may be merit in studying the two constructs separately. Four validated self-assessment measures for cyberchondria are available in literature. Cognitive behaviour therapy (CBT) delivered either physically or through the internet (iCBT) have been found to be effective for both health anxiety and cyberchondria. Pharmacologic strategies for health anxiety have mainly involved the use of Selective Serotonin Reuptake Inhibitors, with mean effective dosages higher than for depression/anxiety. Prevention of cyberchondria needs to focus on appropriate harm reduction strategies as well as supply and demand side measures. Internet based CBT therapies hold promise for management of cyberchondria. This finding must be considered preliminary due to limited evidence. Further study is required to establish the diagnostic validity of cyberchondria.
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Affiliation(s)
- Vikas Menon
- Dept of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Sujita Kumar Kar
- Dept of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Adarsh Tripathi
- Dept of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Naresh Nebhinani
- Dept of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Natarajan Varadharajan
- Dept of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
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Chan CHY, Lau BHP, Chan THY, Leung HT, So GYK, Chan CLW. Examining the Moderating Role of Patient Enablement on the Relationship Between Health Anxiety and Psychosomatic Distress: A Cross-Sectional Study at a Traditional Chinese Medicine Outpatient Clinic in Hong Kong. Front Psychol 2020; 11:1081. [PMID: 32655430 PMCID: PMC7325961 DOI: 10.3389/fpsyg.2020.01081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background Little research effort has been devoted to examining the role of patient enablement in alleviating health anxiety in primary care. In this study, we examined the role of patient enablement as a moderator in the relationship between health anxiety, psychological distress, and treatment seeking in traditional Chinese medicine (TCM). Methods The participants were 634 patients of a government-subsidized Chinese medicine outpatient clinic in Hong Kong. They were asked to complete a series of questionnaires on patient enablement, health anxiety, anxiety, depression, physical distress, annual clinic visits, and service satisfaction and provided various demographic details. Descriptive statistics, correlations, and general linear models were used to analyze the data. Results We found that patient enablement correlated positively with service satisfaction. Patient enablement also interacted significantly with health anxiety in affecting indices of psychological distress (depression, anxiety) and treatment seeking (annual visits). Among highly enabled patients, the positive association between health anxiety and indices of psychological distress was weakened, and they also showed more health anxiety-driven treatment seeking as measured by annual clinic visits. Conclusion These findings suggest a moderating mechanism by which patient enablement weakens the relationship between health anxiety on psychological well-being and increases treatment-seeking behavior in TCM. Practitioners are encouraged to provide sufficient information to patients to foster self-care and disease self-management using complementary and alternative medicine (CAM).
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Affiliation(s)
- Celia H Y Chan
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Bobo H P Lau
- Department of Counselling and Psychology, Hong Kong Shue Yan University, North Point, Hong Kong
| | - Timothy H Y Chan
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - H T Leung
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Georgina Y K So
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Cecilia L W Chan
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
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Newby JM, McElroy E. The impact of internet-delivered cognitive behavioural therapy for health anxiety on cyberchondria. J Anxiety Disord 2020; 69:102150. [PMID: 31739276 DOI: 10.1016/j.janxdis.2019.102150] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/10/2019] [Accepted: 10/09/2019] [Indexed: 12/26/2022]
Abstract
Cyberchondria refers to an emotional-behavioural pattern whereby excessive online searches lead to increased anxiety about one's own health status. It has been shown to be associated with health anxiety, however it is unknown whether existing cognitive behavioural therapy (CBT) interventions targeting health anxiety also improve cyberchondria. This study aimed to determine whether internet-delivered cognitive behavioural therapy (iCBT) for severe health anxiety led to improvements in self-reported cyberchondria and whether improvements in cyberchondria were associated with improvements in health anxiety observed during treatment. Methods: We analysed secondary data from a randomised controlled trial (RCT) comparing an iCBT group (n = 41) to an active control group who underwent psychoeducation, monitoring and clinical support (n = 41) in health anxious patients with a DSM-5 diagnosis of Illness Anxiety Disorder and/or Somatic Symptom Disorder. The iCBT group showed a significantly greater reduction in cyberchondria compared to the control group, with large differences at post-treatment on the Cyberchondria Severity Scale Total scale (CSS; Hedges g = 1.09), and the Compulsion, Distress, Excessiveness subscales of the CSS (g's: 0.8-1.13). Mediation analyses showed improvements in health anxiety in the iCBT group were mediated by improvements in all of the CSS subscales, except for the Mistrust subscale. Conclusions: Internet CBT for health anxiety improves cyberchondria.
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Affiliation(s)
- Jill M Newby
- School of Psychology, UNSW Sydney, 1302 Mathews Building, Randwick, NSW, 2052, Australia; Clinical Research Unit for Anxiety and Depression (CRUfAD), School of Psychiatry, UNSW Sydney at St Vincent's Hospital, 390 Victoria Street Darlinghurst, NSW, Sydney, 2010, Australia.
| | - Eoin McElroy
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, University Road, Leicester, LE1 7RH, UK
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Dynamics of Defensive Response Mobilization to Approaching External Versus Interoceptive Threat. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2018; 3:525-538. [DOI: 10.1016/j.bpsc.2017.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/18/2022]
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Moriana JA, Gálvez-Lara M, Corpas J. Psychological treatments for mental disorders in adults: A review of the evidence of leading international organizations. Clin Psychol Rev 2017; 54:29-43. [PMID: 28384513 DOI: 10.1016/j.cpr.2017.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022]
Abstract
Most mental health services throughout the world currently regard evidence-based psychological treatments as best practice for the treatment of mental disorders. The aim of this study was to analyze evidence-based treatments drawn from RCTs, reviews, meta-analyses, guides, and lists provided by the National Institute for Health and Care Excellence (NICE), Division 12 (Clinical Psychology) of the American Psychological Association (APA), Cochrane and the Australian Psychological Society (APS) in relation to mental disorders in adults. A total of 135 treatments were analyzed for 23 mental disorders and compared to determine the level of agreement among the organizations. The results indicate that, in most cases, there is little agreement among organizations and that there are several discrepancies within certain disorders. These results require reflection on the meaning attributed to evidence-based practice with regard to psychological treatments. The possible reasons for these differences are discussed. Based on these findings, proposals to unify the criteria that reconcile the realities of clinical practice with a scientific perspective were analyzed.
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Affiliation(s)
- Juan Antonio Moriana
- Department of Psychology, University of Cordoba, Spain; Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Spain; Reina Sofia University Hospital, Spain.
| | - Mario Gálvez-Lara
- Department of Psychology, University of Cordoba, Spain; Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Spain; Reina Sofia University Hospital, Spain
| | - Jorge Corpas
- Department of Psychology, University of Cordoba, Spain
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Newby JM, Mahoney AE, Mason EC, Smith J, Uppal S, Andrews G. Pilot trial of a therapist-supported internet-delivered cognitive behavioural therapy program for health anxiety. Internet Interv 2016; 6:71-79. [PMID: 30135816 PMCID: PMC6096191 DOI: 10.1016/j.invent.2016.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 12/28/2022] Open
Abstract
Cognitive behavioural therapy (CBT) is an effective treatment for health anxiety, but more research is needed to evaluate accessible, low cost ways of delivering CBT. Internet CBT may be effective, but there are no iCBT programs available outside of Sweden. We developed the first English-language clinician-guided iCBT program for health anxiety and conducted an open pilot trial (n = 16) to examine its acceptability, and impact on health anxiety and comorbidity, disability, and the cognitive and behavioural factors thought to maintain the disorder (e.g., catastrophising, hypervigilance). 13/16 participants completed the program (81% adherence). We found large and significant reductions in health anxiety, depression, distress, anxiety and disability (g's > 1.0), dysfunctional cognitions, behaviours and body vigilance between pre- and post-treatment, which were maintained at 3-month follow-up. The results provide preliminary support for the use of iCBT for health anxiety. Randomised controlled efficacy trials are now needed to evaluate this program.
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Affiliation(s)
- Jill M. Newby
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Psychology, University of New South Wales, Australia
| | - Alison E.J. Mahoney
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Elizabeth C. Mason
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Jessica Smith
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Shivani Uppal
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Gavin Andrews
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
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Hoffmann D, Halsboe L, Eilenberg T, Jensen JS, Frostholm L. A pilot study of processes of change in group-based acceptance and commitment therapy for health anxiety. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2014. [DOI: 10.1016/j.jcbs.2014.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Van Dessel N, Den Boeft M, van der Wouden JC, Kleinstäuber M, Leone SS, Terluin B, Numans ME, van der Horst HE, van Marwijk H. Non-pharmacological interventions for somatoform disorders and medically-unexplained physical symptoms (MUPS) in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011142] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Chris Williams
- Institute of Health and Wellbeing, University of Glasgow, Administration Building, Gartnavel Royal Hospital, Glasgow G12 0XH, UK.
| | - Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Tyrer P, Cooper S, Salkovskis P, Tyrer H, Crawford M, Byford S, Dupont S, Finnis S, Green J, McLaren E, Murphy D, Reid S, Smith G, Wang D, Warwick H, Petkova H, Barrett B. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet 2014; 383:219-25. [PMID: 24139977 DOI: 10.1016/s0140-6736(13)61905-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Health anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics. METHODS We undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16-75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten sessions of adapted cognitive behaviour therapy (CBT-HA group) delivered by hospital-based therapists or to standard care in the clinics. The primary outcome was change in health anxiety symptoms measured by the Health Anxiety Inventory at 1 year and the main secondary hypothesis was equivalence of total health and social care costs over 2 years, with an equivalence margin of £150. Analysis was by intention to treat. The study is registered with controlled-trials.com, ISRCTN14565822. FINDINGS Of 28,991 patients screened, 444 were randomly assigned to receive either adapted cognitive behaviour therapy (CBT-HA group, 219 participants) or standard care (standard care group, 225), with 205 participants in the CBT-HA group and 212 in the standard care group included in the analyses of the primary endpoints. At 1 year, improvement in health anxiety in the patients in the CBT-HA group was 2·98 points greater than in those in the standard care group (95% CI 1·64-4·33, p<0·0001), and twice as many patients receiving cognitive behaviour therapy achieved normal levels of health anxiety compared with those in the control group (13·9% vs 7·3%; odds ratio 2·15, 95% CI 1·09-4·23, p=0·0273). Similar differences were observed at 6 months and 2 years, and there were concomitant reductions in generalised anxiety and, to a lesser extent, depression. Of nine deaths, six were in the control group; all were due to pre-existing illness. Social functioning or health-related quality of life did not differ significantly between groups. Equivalence in total 2-year costs was not achieved, but the difference was not significant (adjusted mean difference £156, 95% CI -1446 to 1758, p=0·848). INTERPRETATION This form of adapted cognitive behaviour therapy for health anxiety led to sustained symptomatic benefit over 2 years, with no significant effect on total costs. It deserves wider application in medical care. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Peter Tyrer
- Centre for Mental Health, Imperial College, Claybrook Road London, UK.
| | - Sylvia Cooper
- Centre for Mental Health, Imperial College, Claybrook Road London, UK
| | | | - Helen Tyrer
- Centre for Mental Health, Imperial College, Claybrook Road London, UK
| | - Michael Crawford
- Centre for Mental Health, Imperial College, Claybrook Road London, UK
| | - Sarah Byford
- Centre for the Economics of Mental and Physical Health, King's College London, De Crespigny Park, London, UK
| | - Simon Dupont
- Greenacres Centre, Hillingdon Hospital, Pield Heath Road, Uxbridge, UK
| | - Sarah Finnis
- Greenacres Centre, Hillingdon Hospital, Pield Heath Road, Uxbridge, UK
| | - John Green
- Central and North West London NHS Foundation Trust, Hampstead Road, London, UK
| | - Elenor McLaren
- Department of Clinical Psychology, Charing Cross Hospital, Fulham Palace Road, London, UK
| | - David Murphy
- Department of Clinical Psychology, Charing Cross Hospital, Fulham Palace Road, London, UK
| | - Steven Reid
- Central and North West London NHS Foundation Trust, Hampstead Road, London, UK
| | - Georgina Smith
- Central and North West London NHS Foundation Trust, Hampstead Road, London, UK
| | - Duolao Wang
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Hilary Warwick
- Centre for Mental Health, Imperial College, Claybrook Road London, UK
| | - Hristina Petkova
- Centre for the Economics of Mental and Physical Health, King's College London, De Crespigny Park, London, UK
| | - Barbara Barrett
- Centre for the Economics of Mental and Physical Health, King's College London, De Crespigny Park, London, UK
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Hedman E, Lindefors N, Andersson G, Andersson E, Lekander M, Rück C, Ljótsson B. Predictors of outcome in Internet-based cognitive behavior therapy for severe health anxiety. Behav Res Ther 2013; 51:711-7. [DOI: 10.1016/j.brat.2013.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/30/2013] [Accepted: 07/30/2013] [Indexed: 10/26/2022]
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Kleinstäuber M, Witthöft M, Steffanowski A, Lambert M, Meinhardt G, Lieb K, Hiller W. Pharmacological interventions for somatoform disorders in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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17
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Acceptance and commitment group therapy for health anxiety--results from a pilot study. J Anxiety Disord 2013; 27:461-8. [PMID: 23871841 DOI: 10.1016/j.janxdis.2013.06.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 05/03/2013] [Accepted: 06/01/2013] [Indexed: 10/26/2022]
Abstract
Health anxiety (or hypochondriasis) is prevalent, may be persistent and disabling for the sufferers and associated with high societal costs. Acceptance and Commitment Therapy (ACT) is a new third-wave behavioral cognitive therapy that has not yet been tested in health anxiety. 34 consecutive Danish patients with severe health anxiety were referred from general practitioners or hospital departments and received a ten-session ACT group therapy. Patients were followed up by questionnaires for 6 months. There were significant reductions in health anxiety, somatic symptoms and emotional distress at 6 months compared to baseline: a 49% reduction in health anxiety (Whiteley-7 Index), a 47% decrease in emotional distress (SCL-8), and a 40% decrease in somatic symptoms (SCL-90R Somatization Subscale). The patients' emotional representations and perception of the consequences of their illness (IPQ) improved significantly, and 87% of the patients were very or extremely satisfied with the treatment.
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18
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A review of cognitive therapy in acute medical settings. Part I: Therapy model and assessment. Palliat Support Care 2012; 11:141-53. [DOI: 10.1017/s147895151200082x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings?Method:Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.)Results:Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized.Significance of results:The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.
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Sørensen P, Birket-Smith M, Wattar U, Buemann I, Salkovskis P. A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis. Psychol Med 2011; 41:431-441. [PMID: 20380779 DOI: 10.1017/s0033291710000292] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hypochondriasis is common in the clinic and in the community. Cognitive behavioural therapy (CBT) has been found to be effective in previous trials. Psychodynamic psychotherapy is a treatment routinely offered to patients with hypochondriasis in many countries, including Denmark. The aim of this study was to test CBT for hypochondriasis in a centre that was not involved in its development and compare both CBT and short-term psychodynamic psychotherapy (STPP) to a waiting-list control and to each other. CBT was modified by including mindfulness and group therapy sessions, reducing the therapist time required. STPP consisted of individual sessions. METHOD Eighty patients randomized to CBT, STPP and the waiting list were assessed on measures of health anxiety and general psychopathology before and after a 6-month treatment period. Waiting-list patients were subsequently offered one of the two active treatments on the basis of re-randomization, and assessed on the same measures post-treatment. Patients were again assessed at 6- and 12-month follow-up points. RESULTS Patients who received CBT did significantly better on all measures relative to the waiting-list control group, and on a specific measure of health anxiety compared with STPP. The STPP group did not significantly differ from the waiting-list group on any outcome measures. Similar differences were observed between CBT and STPP during follow-up, although some of the significant differences between groups were lost. CONCLUSIONS A modified and time-saving CBT programme is effective in the treatment of hypochondriasis, although the two psychotherapeutic interventions differed in structure.
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Affiliation(s)
- P Sørensen
- Liaison Psychiatry Unit, Psykiatrisk Centre Copenhagen, Copenhagen University Hospital, Denmark.
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Kleinstäuber M, Witthöft M, Hiller W. Efficacy of short-term psychotherapy for multiple medically unexplained physical symptoms: A meta-analysis. Clin Psychol Rev 2011; 31:146-60. [DOI: 10.1016/j.cpr.2010.09.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 05/21/2010] [Accepted: 09/06/2010] [Indexed: 10/19/2022]
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Abstract
Patients presenting with somatoform disorders often incur excessive health care charges and fail to respond to standard treatment. The purpose of this article is to provide an overview of the diagnostic criteria and demographic and clinical characteristics of each somatoform disorder and to examine the research assessing the efficacy of cognitive behavioral therapy (CBT) for each disorder. The review shows that CBT has received some empirical support for somatization, hypochondriasis, and body dysmorphic disorder. However, there are few data on the impact of treatment on health care use, especially when the cost of CBT is factored into the equation. Too few methodologically sound studies have been published on the treatment of conversion disorder or of pain disorder to make any conclusions.
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Affiliation(s)
- Lesley A Allen
- Department of Psychiatry, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, 671 Hoes Lane, Piscataway, NJ 08854, USA.
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Hoedeman R, Blankenstein AH, Krol B, Koopmans PC, Groothoff JW. The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge. JOURNAL OF OCCUPATIONAL REHABILITATION 2010; 20:264-73. [PMID: 20373134 PMCID: PMC2887510 DOI: 10.1007/s10926-010-9239-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
INTRODUCTION The primary objectives were to compare the duration of sickness absence in employees with high levels of somatic symptom severity (HLSSS) with employees with lower levels of somatic symptom severity, and to establish the long-term outcomes concerning return to work (RTW), disability and discharge. Secondary objective was to evaluate determinants of the duration of sickness absence in employees with HLSSS. METHODS 489 sick-listed employees registered with five Occupational Health Physician (OHP) group practices were included in this study. We measured their baseline scores for somatic symptoms severity, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. The OHPs filled in a questionnaire on their diagnosis. A prospective 2-year follow-up was carried out to assess the long-term outcomes concerning sickness absence, and retrospective information was gathered with regard to sickness absence during the 12 months before the employees were sick-listed. RESULTS The median duration of sickness absence was 78 days longer for employees with HLSSS. They more often remained disabled and were discharged more often, especially due to problems in the relationship between the employer and the employee. HLSSS, health anxiety and older age contributed to a longer duration of sickness absence of employees. CONCLUSION High levels of somatic symptom severity are a determinant of prolonged sickness absence, enduring disabilities and health-related job loss. Occupational health physicians should identify employees who are at risk and adhere to guidelines for medically unexplained somatic symptoms.
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Affiliation(s)
- Rob Hoedeman
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Phillips KA, Stein DJ, Rauch SL, Hollander E, Fallon BA, Barsky A, Fineberg N, Mataix-Cols D, Ferrão YA, Saxena S, Wilhelm S, Kelly MM, Clark LA, Pinto A, Bienvenu OJ, Farrow J, Leckman J. Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depress Anxiety 2010; 27:528-55. [PMID: 20533367 PMCID: PMC3985410 DOI: 10.1002/da.20705] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.
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Muse K, McManus F, Hackmann A, Williams M, Williams M. Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles. Behav Res Ther 2010; 48:792-8. [PMID: 20627270 PMCID: PMC3004028 DOI: 10.1016/j.brat.2010.05.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 04/15/2010] [Accepted: 05/10/2010] [Indexed: 11/16/2022]
Abstract
Increased understanding of the nature and role of intrusive imagery has contributed to the development of effective treatment protocols for some anxiety disorders. However, intrusive imagery in severe health anxiety (hypochondriasis) has been comparatively neglected. Hence, the current study investigates the prevalence, nature and content of intrusive imagery in 55 patients who met DSM-IV-TR (APA, 2000) criteria for the diagnosis of hypochondriasis. A semi-structured interview was used to assess the prevalence, nature and possible role of intrusive imagery in this disorder. Over 78% of participants reported experiencing recurrent, distressing intrusive images, the majority (72%) of which either were a memory of an earlier event or were strongly associated with a memory. The images tended to be future orientated, and were reliably categorised into four themes: i) being told ‘the bad news’ that you have a serious/life threatening-illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%). Participants reported responding to experiencing intrusive images by engaging in avoidance, checking, reassurance seeking, distraction and rumination. Potential treatment implications and links to maintenance cycles are considered.
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Affiliation(s)
- Kate Muse
- University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom
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Ravindran AV, da Silva TL, Ravindran LN, Richter MA, Rector NA. Obsessive-compulsive spectrum disorders: a review of the evidence-based treatments. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2009; 54:331-43. [PMID: 19497165 DOI: 10.1177/070674370905400507] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide a review of the evidence-based treatments for obsessive-compulsive spectrum disorders (OCSD), a group of conditions related to obsessive-compulsive disorder (OCD) by phenomenological and etiological similarities, the morbidity of which is increasingly recognized. METHOD Literature relating to the following disorders: body dysmorphic disorder, hypochondriasis, trichotillomania, onychophagia, psychogenic excoriation, compulsive buying, kleptomania, and pathological gambling, and published between January 1965 and October 2007, was found using PubMed. Included in this review were 107 treatment reports. RESULTS Serotonin reuptake inhibitors (SRIs) have shown benefits as first-line, short-term treatments for body dysmorphic disorder, hypochondriasis, onychophagia, and psychogenic excoriation, with some benefits in trichotillomania, pathological gambling, and compulsive buying. There are also suggested benefits for several atypical antipsychotics in disorders with a high degree of impulsivity, including trichotillomania and pathological gambling, and to a lesser extent, kleptomania and psychogenic excoriation. Cognitive-behavioural interventions have generally shown evidence for use as first-line treatment across the spectrum, with some variability in degree of benefit. CONCLUSIONS As in OCD, several conditions in the proposed OCSD benefit from SRIs and (or) cognitive-behavioural interventions. However, the treatment literature is generally limited, and more randomized controlled trials (RCTs) are needed to evaluate individual and combination treatments, for short-term use and as maintenance.
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