The clinical implications of personality-generated mental illness

Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years

BACKGROUND

Health anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive-behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medical outpatients.

DESIGN

Randomised controlled trial.

SETTING

Five general hospitals in London, Middlesex and Nottinghamshire.

PARTICIPANTS

A total of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics who scored ≥ 20 points on the Health Anxiety Inventory (HAI) and satisfied diagnostic requirements for hypochondriasis. Those with current psychiatric disorders were excluded, but those with concurrent medical illnesses were not.

INTERVENTIONS

Cognitive-behaviour therapy for health anxiety - between 4 and 10 1-hour sessions of CBT-HA from a health professional or psychologist trained in the treatment. Standard care was normal practice in primary and secondary care.

MAIN OUTCOME MEASURES

Primary - researchers masked to allocation assessed patients at baseline, 3, 6, 12, 24 months and 5 years. The primary outcome was change in the HAI score between baseline and 12 months. Main secondary outcomes - costs of care in the two groups after 24 and 60 months, change in health anxiety (HAI), generalised anxiety and depression [Hospital Anxiety and Depression Scale (HADS)] scores, social functioning using the Social Functioning Questionnaire and quality of life using the EuroQol-5 Dimensions (EQ-5D), at 6, 12, 24 and 60 months, and deaths over 5 years.

RESULTS

Of the 28,991 patients screened over 21 months, 5769 had HAI scores of ≥ 20 points. Improvement in HAI scores at 3 months was significantly greater in the CBT-HA group (mean number of sessions = 6) than in the standard care, and this was maintained over the 5-year period (overall p < 0.0001), with no loss of efficacy between 2 and 5 years. Differences in the generalised anxiety (p = 0.0018) and depression scores (p = 0.0065) on the HADS were similar in both groups over the 5-year period. Gastroenterology and cardiology patients showed the greatest CBT gains. The outcomes for nurses were superior to those of other therapists. Deaths (n = 24) were similar in both groups; those in standard care died earlier than those in CBT-HA. Patients with mild personality disturbance and higher dependence levels had the best outcome with CBT-HA. Total costs were similar in both groups over the 5-year period (£12,590.58 for CBT-HA; £13,334.94 for standard care). CBT-HA was not cost-effective in terms of quality-adjusted life-years, as measured using the EQ-5D, but was cost-effective in terms of HAI outcomes, and offset the cost of treatment.

LIMITATIONS

Many eligible patients were not randomised and the population treated may not be representative.

CONCLUSIONS

CBT-HA is a highly effective treatment for pathological health anxiety with lasting benefit over 5 years. It also improves generalised anxiety and depressive symptoms more than standard care. The presence of personality abnormality is not a bar to successful outcome. CBT-HA may also be cost-effective, but the high costs of concurrent medical illnesses obscure potential savings. This treatment deserves further research in medical settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14565822.

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. 21, No. 50. See the NIHR Journals Library website for further project information.

Impact of personality status on the outcomes and cost of cognitive-behavioural therapy for health anxiety

BACKGROUND

Health anxiety, hypochondriasis and personality disturbance commonly coexist. The impact of personality status was assessed in a secondary analysis of a randomised controlled trial (RCT).

AIMS

To test the impact of personality status using ICD-11 criteria on the clinical and cost outcomes of treatment with cognitive-behavioural therapy for health anxiety (CBT-HA) and standard care over 2 years.

METHOD

Personality dysfunction was assessed at baseline in 444 patients before randomisation and independent assessment of costs and outcomes made on four occasions over 2 years.

RESULTS

In total, 381 patients (86%) had some personality dysfunction with 184 (41%) satisfying the ICD criteria for personality disorder. Those with no personality dysfunction showed no treatment differences (P = 0.90) and worse social function with CBT-HA compared with standard care (P<0.03) whereas all other personality groups showed greater improvement with CBT-HA maintained over 2 years (P<0.001). Less benefit was shown in those with more severe personality disorder (P<0.05). Costs were less with CBT-HA except for non-significant greater differences in those with moderate or severe personality disorder.

CONCLUSIONS

The results contradict the hypothesis that personality disorder impairs response to CBT in health anxiety in both the short and medium term.

Constructing a short form of the hierarchical personality inventory for children (HiPIC): the HiPIC-30

Children's personality traits are invaluable predictors of concurrent and later mental and physical health. Several validated longer inventories for assessing the widely recognized Five-Factor Model of personality in children are available, but short forms are scarce. This study aimed at constructing a 30-item form of the 144-item Hierarchical Personality Inventory for Children (HiPIC) (Mervielde & De Fruyt, ). Participants were 1543 children aged 6-12 years (sample 1) and 3895 children aged 8 years (sample 2). Sample 1 completed the full HiPIC, from which we constructed the HiPIC-30, and the Child Behaviour Checklist (Achenbach, ). Sample 2 completed the HiPIC-30. The HiPIC-30 personality domains correlated over r = .90 with the full HiPIC domains, had good Cronbach's alphas and correlated similarly with CBCL behaviour problems and gender as the full HiPIC. The factor structures of the HiPIC-30 were convergent across samples, but the imagination factor was not clear-cut. We conclude that the HiPIC-30 is a reliable and valid questionnaire for the Five-Factor personality traits in children. Copyright © 2016 John Wiley & Sons, Ltd.