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Rask CU, Duholm CS, Poulsen CM, Rimvall MK, Wright KD. Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences. J Child Psychol Psychiatry 2024; 65:413-430. [PMID: 37909255 DOI: 10.1111/jcpp.13912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 11/03/2023]
Abstract
Health anxiety involves excessive worries about one's health along with beliefs one has an illness or may contract a serious disease. Concerning evidence suggests that health anxiety is on the rise in society, possibly further fueled by the COVID-19 pandemic. Recent classification systems acknowledge that impairing health-related worries and beliefs can emerge in early childhood with significant levels of symptoms persisting throughout childhood, and possibly continuous with diagnostic considerations in adulthood. This narrative review summarizes recent research advances in health anxiety in children and adolescents, focusing on various developmental aspects of health anxiety and related concepts in youths. Findings suggest that health anxiety symptoms in young age groups are associated with impairment, distress, and increased healthcare use, as well as substantial comorbidity with mainly other emotional problems and disorders. Furthermore, longitudinal studies suggest that childhood health anxiety can persist across adolescence, perhaps with links to chronic courses in adulthood. The growing literature was further reviewed, thus extending our understanding of early risk factors, including the potential role of exposure to serious illness and transgenerational transmission of health anxiety. Learning more about developmental trajectories will be highly relevant to inform strategies for early detection and prevention. While modified cognitive behavioral therapies in adults are successful in treating health anxiety, specific interventions have not yet been tested in youths. Given substantial overlaps with other psychopathology, it could be important to develop and explore more transdiagnostic and scalable approaches that take advantage of common factors in psychotherapy, while also including a wider perspective on potential familiar maladaptive illness cognitions and behaviors.
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Affiliation(s)
- Charlotte Ulrikka Rask
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Charlotte Steen Duholm
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Martin Køster Rimvall
- Department of Child and Adolescent Psychiatry, Copenhagen University Hospital - Psychiatry Region Zealand, Roskilde, Denmark
- Child and Adolescent Mental Health Center, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Kristi D Wright
- Department of Psychology, University of Regina, Regina, SK, Canada
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Ingeman K, Wright KD, Frostholm L, Frydendal DH, Ørnbøl E, Rask CU. Measurement properties of the Health Anxiety by Proxy Scale (HAPYS): A new questionnaire to assess parents' worries about their child's health. J Psychosom Res 2024; 176:111555. [PMID: 38039620 DOI: 10.1016/j.jpsychores.2023.111555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Health anxiety by proxy refers to parents' excessive worries about their child's health. The Health Anxiety by Proxy scale (HAPYS) is a new self-report questionnaire to assess parents' worries and behaviors regarding their child's health. This study aimed to investigate the measurement properties of the HAPYS. METHODS Questionnaires were completed by 204 parents, and a HAPYS score was obtained for 200 parents: 39 parents diagnosed with health anxiety, 33 parents with different anxiety disorders, 33 parents with a Functional Somatic Disorder, and 95 healthy parents. We evaluated the following measurement properties: structural validity, reliability, convergent validity ((pain catastrophizing, parents' reports of child's emotional and physical symptoms), discriminant validity (parental reports of child's well-being), and known-groups validity (see compared groups above). RESULTS HAPYS demonstrated a one factor dimensionality, and excellent internal reliability (α = 0.95; CI: 0.93-0.97) and test-retest reliability after two weeks (ICC = 0.91; CI: 0.87-0.94). Convergent validity with the construct of parental catastrophizing about child pain was good (r = 0.72; CI: 0.64-0.78)). Good known-groups validity was demonstrated by the largest total HAPYS score observed in parents with health anxiety (median = 35; IQR: 9-53) and the lowest score in healthy parents (median = 9; IQR: 5-15) (p < 0.001). CONCLUSION The findings support that HAPYS is a useful measure of health anxiety by proxy. Future research should examine the measurement properties in larger samples and different languages with further statistical analyses of structural validity.
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Affiliation(s)
- Katrine Ingeman
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Palle Juul-Jensens Boulevard 175, 8200 Aarhus, Denmark; The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Universitetsbyen 21-23, 8000 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark.
| | - Kristi D Wright
- Department of Psychology, Faculty of Arts, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
| | - Lisbeth Frostholm
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Universitetsbyen 21-23, 8000 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark
| | - Ditte Hoffmann Frydendal
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Universitetsbyen 21-23, 8000 Aarhus, Denmark
| | - Eva Ørnbøl
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Universitetsbyen 21-23, 8000 Aarhus, Denmark
| | - Charlotte Ulrikka Rask
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Palle Juul-Jensens Boulevard 175, 8200 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark
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Barbek R, Henning S, Ludwig J, von dem Knesebeck O. Ethnic and migration-related inequalities in health anxiety: A systematic review and meta-analysis. Front Psychol 2022; 13:960256. [PMID: 36092037 PMCID: PMC9462455 DOI: 10.3389/fpsyg.2022.960256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Health anxiety exists on a continuum ranging from the absence of health awareness to the obsessive fear of having a serious illness despite reassurance. Its pathological manifestation can be diagnosed as hypochondriacal or illness anxiety or somatic symptom disorder. Health anxiety is associated with psychological distress and adverse life events, among others, and leads to considerable economic burden. Compared to the majority population, migrants, and ethnic minorities often face major health inequalities. Several mental illnesses and psychosomatic complaints are more common among these groups. To date, potential ethnic and migration-related inequalities in health anxiety have not been clearly described. However, they are of high relevance for the provision of adequate health care of this diverse and potentially vulnerable group. Thus, we conducted a systematic review and meta-analysis of health anxiety in migrants and ethnic minorities. Methods A systematic literature search of PubMED, Web of Science, PsycINFO, and PSYNDEX was conducted, covering all studies published until 1st of December 2021. Studies were selected if they employed validated measurement tools of health anxiety and examined migrants and/or ethnic minorities in comparison with the majority population. Meta-analytic methods were applied by using a random-effect model. The study quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Results We identified 18 studies from 445 studies initially screened. Of these, 14 studies conducted in North America with a total number of 5,082 study participants were included in the meta-analysis. The pooled effect size indicated a higher risk of health anxiety in migrants and ethnic minorities compared to the majority population (OR 1.39, 95%-CI 1.01-1.92). The results proved not to be robust according to publication bias (adjusted OR 1.18, 95%-CI 0.83-1.69) and fail-safe N (2/3 < benchmark N = 75) and are limited due to heterogeneity (I 2 = 57%), small sample sizes and an overall low quality of included studies. Conclusion To address the diversity of migrants and ethnic minorities, inter-sectional approaches across different countries are needed in research to shed further light on social inequalities in health anxiety linked to migration. Systematic review registration PROSPERO, registration number CRD42022298458.
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Affiliation(s)
- Rieke Barbek
- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Yusefi AR, Daneshi S, Davarani ER, Nikmanesh P, Mehralian G, Bastani P. Resilience level and its relationship with hypochondriasis in nurses working in COVID-19 reference hospitals. BMC Nurs 2021; 20:219. [PMID: 34727947 PMCID: PMC8561347 DOI: 10.1186/s12912-021-00730-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/06/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION A new coronavirus, called COVID-19, is an acute respiratory disease, which may arouse many psychological disorders since there is no specialized knowledge about it. The present study aimed to investigate the level of resilience and its relationship with hypochondriasis in nurses working in a COVID-19 reference hospital in south of Iran. METHODS This cross-sectional study was conducted in 2020, in which 312 nurses participated using the census method. Data collection tools were the Conker-Davidson standard resilience scale (CD-RISC) and the Evans Hypoglycaemia Awareness Questionnaire. Data were analyzed using t-test, ANOVA, Pearson correlation coefficient, and multiple linear regression using SPSS software version 23. RESULTS The mean scores of resilience and hypochondriasis were 72.38 ± 7.11 and 49.75 ± 8.13, respectively, indicating the moderate level of these two variables among nurses. Hypochondriasis in 18.91, 61.22, and 1.28% of the nurses was mild, moderate, and severe, respectively. There was a significant negative correlation between resilience and hypochondriasis (r = - 0.214 and P < 0.001). In this regard, control (P < 0.001), positive acceptance of change (P < 0.001), spiritual effects (P = 0.001), trust in individual instincts (P = 0.001), and perception of competence (P = 0.002) were detected as the predictors of nurses' hypochondriasis. CONCLUSION The nurses had moderate levels of resilience and hypochondriasis. Promoting knowledge about COVID-19and increasing information on how to protect oneself and others against the disease along with supportive packages from their managers are thus recommended.
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Affiliation(s)
- Ali Reza Yusefi
- Department of Public Health, Healthcare Services Management, School of Health, Jiroft University of Medical Science, Jiroft, Iran
| | - Salman Daneshi
- Department of Public Health, Jiroft University of Medical Sciences, Jiroft, Iran
| | - Esmat Rezabeigi Davarani
- Health in Disasters and Emergencies Research Center, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Parnian Nikmanesh
- Healthcare Services Management, School of Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamhossein Mehralian
- Department of Pharmacoeconomics and Pharmacy Administration, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Peivand Bastani
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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Carstensen TBW, Ørnbøl E, Fink P, Pedersen MM, Jørgensen T, Dantoft TM, Benros ME, Frostholm L. Detection of illness worry in the general population: A specific item on illness rumination improves the Whiteley Index. J Psychosom Res 2020; 138:110245. [PMID: 32950761 DOI: 10.1016/j.jpsychores.2020.110245] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/21/2020] [Accepted: 09/07/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The Whiteley Index (WI) is the most widely used screening tool for health anxiety/illness worry. Diverse versions (different number of items and factors) have been used. We aimed to examine psychometric properties of 7 items of the WI besides adding a new item on obsessive illness rumination for better future detection of health anxiety. METHODS Data from a large population-based study in Denmark (N = 9656). Construct validity was examined by exploratory (EFA) and confirmatory factor analysis (CFA) plus hypothesis testing. Criterion validity was evaluated via Receiver Operating Characteristic curves and area under the curve (AUC) using a diagnostic criterion as gold standard. RESULTS Factor loadings of EFA revealed viable one-factor models (6, 7, or 8 items) and two-factor models (7 or 8 items). Factor one indicated a dimension of illness worry. Factor two indicated a somatic symptoms dimension. The new item on obsessive illness rumination merged well with the existing items. EFA of two-factor models and one-factor 6-item model showed good fit. CFA resembles these findings. A one-factor 6-item model (including the item on obsessive illness rumination and excluding two items concerning somatic symptoms) was chosen as the optimal model and presented good criterion validity: AUC 0.88 (95%CI(0.84;0.92)). Main hypotheses concerning associations with somatic symptoms, anxiety, and depression were met. CONCLUSIONS We found good psychometric properties for a new one-factor 6-item version of the WI. Through elimination of items concerning somatic symptoms and inclusion of obsessive illness rumination, we propose a clear, unidimensional and improved measure of illness worry: Whiteley-6-R.
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Affiliation(s)
- Tina Birgitte Wisbech Carstensen
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus University, Aarhus, Denmark.
| | - Eva Ørnbøl
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus University, Aarhus, Denmark.
| | - Per Fink
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus University, Aarhus, Denmark.
| | - Majbritt Mostrup Pedersen
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus University, Aarhus, Denmark.
| | - Torben Jørgensen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Capital Region, Denmark; Department of Public Health, Faculty of Medical Sciences, University of Copenhagen, Denmark; Faculty of Medicine, Aalborg University, Denmark.
| | - Thomas Meinertz Dantoft
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Capital Region, Denmark.
| | - Michael Eriksen Benros
- Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Denmark.
| | - Lisbeth Frostholm
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus University, Aarhus, Denmark.
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Abstract
Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms. An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collaboration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.
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Seitz T, Stastka K, Schiffinger M, Rui Turk B, Löffler-Stastka H. Interprofessional care improves health-related well-being and reduces medical costs for chronic pain patients. Bull Menninger Clin 2019; 83:105-127. [PMID: 30840490 DOI: 10.1521/bumc_2019_83_01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This study evaluated whether patients with somatic symptom disorder, expressing chronic pain that could not be attributed to a medical condition, would benefit from an 8-week inpatient residence at a psychiatric ward. In the 1-year follow-up after termination the authors examined the extent to which the integrated treatment decreased patient costs. A total of 106 patients participated in the follow-up and reported a significant improvement in their general health (Cohen's d = 1.5-2.21), a decrease in impairment due to pain (d = 2.24), and a decrease in symptom severity (d = 1.29). They took fewer medications and sick days, reported fewer hospital stays and medical examinations, and consulted and changed physicians and outpatient clinics less often (d = 0.55-1.1). The average cost per patient was cut in half, down to € 80,000/$96,000 per year. From a clinical standpoint, group analysis that focused on aggression was the most effective intervention.
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Affiliation(s)
- Tamara Seitz
- Medical University of Vienna, Department of Psychoanalysis and Psychotherapy, and Teaching Center/Postgraduate Unit/Health Care Management and Psychotherapy Research, Vienna, Austria
- SMZ Süd Hospital of Vienna, Department of Infectious Diseases and Tropical Medicine, Vienna, Austria
| | - Kurt Stastka
- SMZ Süd Hospital of Vienna, Department of Psychiatry, Vienna, Austria
| | | | - Bela Rui Turk
- Kennedy Krieger Institute, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Henriette Löffler-Stastka
- Medical University of Vienna, Department of Psychoanalysis and Psychotherapy, and Teaching Center/Postgraduate Unit/Health Care Management and Psychotherapy Research, Vienna, Austria
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Tyrer P, Salkovskis P, Tyrer H, Wang D, Crawford MJ, Dupont S, Cooper S, Green J, Murphy D, Smith G, Bhogal S, Nourmand S, Lazarevic V, Loebenberg G, Evered R, Kings S, McNulty A, Lisseman-Stones Y, McAllister S, Kramo K, Nagar J, Reid S, Sanatinia R, Whittamore K, Walker G, Philip A, Warwick H, Byford S, Barrett B. Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years. Health Technol Assess 2018; 21:1-58. [PMID: 28877841 DOI: 10.3310/hta21500] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Peter Tyrer
- Centre for Psychiatry, Imperial College London, London, UK
| | | | - Helen Tyrer
- Centre for Psychiatry, Imperial College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Simon Dupont
- Central and North West London NHS Foundation Trust, London, UK
| | - Sylvia Cooper
- Centre for Psychiatry, Imperial College London, London, UK
| | - John Green
- Central and North West London NHS Foundation Trust, London, UK
| | - David Murphy
- Imperial College Healthcare NHS Trust, London, UK
| | - Georgina Smith
- Central and North West London NHS Foundation Trust, London, UK
| | | | | | - Valentina Lazarevic
- East Midlands & South Yorkshire Mental Health Research Network, Nottingham, UK
| | | | - Rachel Evered
- North London Hub, Mental Health Research Network, London, UK
| | - Stephanie Kings
- East Midlands & South Yorkshire Mental Health Research Network, Nottingham, UK
| | | | | | | | - Kofi Kramo
- Centre for Psychiatry, Imperial College London, London, UK
| | - Jessica Nagar
- North London Hub, Mental Health Research Network, London, UK
| | - Steven Reid
- Central and North West London NHS Foundation Trust, London, UK
| | | | | | - Gemma Walker
- Centre for Psychiatry, Imperial College London, London, UK
| | - Aaron Philip
- Centre for Psychiatry, Imperial College London, London, UK
| | - Hilary Warwick
- Centre for Psychiatry, Imperial College London, London, UK
| | - Sarah Byford
- King's Health Economics, King's College London, London, UK
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Doherty-Torstrick ER, Walton KE, Barsky AJ, Fallon BA. Avoidance in hypochondriasis. J Psychosom Res 2016; 89:46-52. [PMID: 27663110 DOI: 10.1016/j.jpsychores.2016.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 07/07/2016] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED The DSM-5 diagnosis of illness anxiety disorder adds avoidance as a component of a behavioral response to illness fears - one that was not present in prior DSM criteria of hypochondriasis. However, maladaptive avoidance as a necessary or useful criterion has yet to be empirically supported. METHODS 195 individuals meeting DSM-IV criteria for hypochondriasis based on structured interview completed a variety of self-report and clinician-administered assessments. Data on maladaptive avoidance were obtained using the six-item subscale of the clinician-administered Hypochondriasis - Yale Brown Obsessive Compulsive Scale - Modified. To determine if avoidance emerged as a useful indicator in hypochondriasis, we compared the relative fit of continuous latent trait, categorical latent class, and hybrid factor mixture models. RESULTS A two-class factor mixture model fit the data best, with Class 1 (n=147) exhibiting a greater level of severity of avoidance than Class 2 (n=48). The more severely avoidant group was found to have higher levels of hypochondriacal symptom severity, functional impairment, and anxiety, as well as lower quality of life. CONCLUSION These results suggest that avoidance may be a valid behavioral construct and a useful component of the new diagnostic criteria of illness anxiety in the DSM-5, with implications for somatic symptom disorder.
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Affiliation(s)
| | | | - Arthur J Barsky
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
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Cyberchondria: Parsing Health Anxiety From Online Behavior. PSYCHOSOMATICS 2016; 57:390-400. [PMID: 27044514 DOI: 10.1016/j.psym.2016.02.002] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/30/2016] [Accepted: 02/01/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Individuals with questions about their health often turn to the Internet for information about their symptoms, but the degree to which health anxiety is related to online checking, and clinical variables, remains unclear. The clinical profiles of highly anxious Internet checkers, and the relationship to checking behavior itself, have not previously been reported. OBJECTIVE In this article, we test the hypothesis, derived from cognitive-behavioral models, that individuals with higher levels of illness anxiety would recall having experienced worsening anxiety after reassurance-seeking on the Internet. METHOD Data from 731 volunteers who endorsed engaging in online symptom-searching were collected using an online questionnaire. Severity of health anxiety was assessed with the Whiteley Index, functional impairment with the Sheehan Disability Scale, and distress recall during and after searching with a modified version of the Clinician׳s Global Impairment scale. Multiple regression analyses were conducted to determine variables contributing to distress during and after Internet checking. RESULTS Severity of illness anxiety on the Whiteley Index was the strongest predictor of increase in anxiety associated with, and consequent to, online symptom-searching. Individuals with high illness anxiety recalled feeling worse after online symptom-checking, whereas those with low illness anxiety recalled relief. Longer-duration online health-related use was associated with increased functional impairment, less education, and increased anxiety during and after checking. CONCLUSION Because individuals with moderate-high levels of illness anxiety recall experiencing more anxiety during and after searching, such searching may be detrimental to their health. If replicated in controlled experimental settings, this would suggest that individuals with illness anxiety should be advised to avoid using the Internet for illness-related information.
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Health Anxiety and Its Relationship to Disability and Service Use: Findings From a Large Epidemiological Survey. Psychosom Med 2016; 78:13-25. [PMID: 26588821 DOI: 10.1097/psy.0000000000000252] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To explore the contribution of health anxiety to disability and use of mental health and medical services, independently of co-occurring mental and physical conditions. METHODS Data from the Australian National Survey of Mental Health and Wellbeing 2007 were analyzed (n = 8841). Participants were aged 16 to 85 years (mean [standard deviation] = 46.3 [19.0] years) and 54% were women. RESULTS Health anxiety accounted independently for high disability and service use. People with health anxiety were more likely to use both mental health (for psychiatrists: odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.2-3.5; for psychologists: OR = 1.9, 95% CI = 1.2-3.3) and specialist medical services (OR = 1.7, 95% CI = 1.2-2.3) than people without health anxiety. However, they were not high-frequency attenders to specialist mental health services (OR = 1.6 [95% CI = 0.9-3.0] and OR = 1.3 [95% CI = 0.6-2.9]) compared with people with other mental disorders (OR = 11.7 [95% CI = 4.3-31.8] and OR = 29.5 [95% CI = 13.5-64.6] for psychiatrists and psychologists, respectively). People with health anxiety were likely to be high-frequency attenders to general practice (OR = 2.0, 95% CI = 1.4-2.8) and specialist medical services (OR = 2.4, 95% CI = 1.7-3.6). CONCLUSIONS It is important to recognize and treat health anxiety, even when coexisting with other conditions, to prevent high disability burden and excessive service use. The cross-sectional design and self-reported outcomes may have resulted in overestimation of the associations. Future work is needed on actual service use using reviews of medical records.
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Eilenberg T, Fink P, Jensen JS, Rief W, Frostholm L. Acceptance and commitment group therapy (ACT-G) for health anxiety: a randomized controlled trial. Psychol Med 2016; 46:103-115. [PMID: 26281857 DOI: 10.1017/s0033291715001579] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Severe health anxiety is frequent and costly, yet rarely diagnosed or treated. Earlier treatment studies show problems with recruitment, dropout and recovery. In the current study, the authors aimed to test the effect of acceptance and commitment group therapy (ACT-G) compared to waitlist in patients with severe health anxiety. METHOD During March 2010 to April 2012, 126 consecutively referred patients meeting research criteria for severe health anxiety were block-randomized (1:1) to ACT-G or a 10 months' waitlist (Clinicaltrials.gov, no. NCT01158430). Patients allocated to ACT-G were treated in seven groups of nine patients between December 2010 and October 2012 and received nine weekly 3-h group sessions and a booster session consisting of ACT techniques. The primary outcome was decided a priori as the mean change in self-reported illness worry on the Whiteley-7 Index (WI) from baseline to 10 months' follow-up. Secondary outcomes were improvement in emotional distress and health-related quality of life at 10 months' follow-up. RESULTS Intention-to-treat analysis showed a statistically significant mean difference of 20.5 points [95% confidence interval (CI) 11.7-29.4, p < 0.001] on the WI between the groups at 10 months, and the between-group effect sizes were large (Cohen's d = 0.89, 95% CI 0.50-1.29). The number needed to treat was 2.4 (95% CI 1.4-3.4, p < 0.001). Diagnosis and treatment were well accepted by the patients. CONCLUSIONS ACT-G seems feasible, acceptable and effective in treating severe health anxiety.
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Affiliation(s)
- T Eilenberg
- The Research Clinic for Functional Disorders and Psychosomatics,Aarhus University Hospital,Aarhus,Denmark
| | - P Fink
- The Research Clinic for Functional Disorders and Psychosomatics,Aarhus University Hospital,Aarhus,Denmark
| | - J S Jensen
- The Research Clinic for Functional Disorders and Psychosomatics,Aarhus University Hospital,Aarhus,Denmark
| | - W Rief
- Department of Clinical Psychology and Psychotherapy,University of Marburg,Marburg,Germany
| | - L Frostholm
- The Research Clinic for Functional Disorders and Psychosomatics,Aarhus University Hospital,Aarhus,Denmark
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Long-term consequences of severe health anxiety on sick leave in treated and untreated patients: Analysis alongside a randomised controlled trial. J Anxiety Disord 2015; 32:95-102. [PMID: 25935314 DOI: 10.1016/j.janxdis.2015.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 04/07/2015] [Accepted: 04/07/2015] [Indexed: 11/23/2022]
Abstract
Health anxiety (HA) is prevalent and costly for health services. However, little is known about the full societal burden of HA. Based on complete register data, we (1) compared weeks on sickness-related benefits (SB) in untreated patients with severe HA (n=126) with a matched population sample (n=12,600); and (2) tested whether Acceptance & Commitment group Therapy (ACT-G) (n=63) reduced weeks on SB during the first year after randomisation compared to a waitlist (n=63). We found that (1) HA patients showed a six-monthly increment of 2 weeks on SB compared with the general population (p<0.0001), and (2) that ACT-G and the waitlist showed no difference in their ability to reduce SB during the first year (p=0.246). We conclude that HA is associated with a considerable societal burden. A possible beneficial effect of psychotherapy on SB needs further investigation.
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14
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Tyrer H, Tyrer P, Lisseman-Stones Y, McAllister S, Cooper S, Salkovskis P, Crawford MJ, Dupont S, Green J, Murphy D, Wang D. Therapist differences in a randomised trial of the outcome of cognitive behaviour therapy for health anxiety in medical patients. Int J Nurs Stud 2014; 52:686-94. [PMID: 25542343 DOI: 10.1016/j.ijnurstu.2014.11.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 11/21/2014] [Accepted: 11/26/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Health anxiety is common in medical settings and can be treated successfully by cognitive behaviour therapy. However it is not clear who might be best placed to deliver this therapy. OBJECTIVES In a planned secondary analysis of data from a randomised trial of adapted cognitive behaviour therapy for health anxiety we compared outcomes of therapy delivered by nurses and other professional groups. DESIGN A randomised controlled trial with two treatment arms, 5-10 sessions of cognitive behaviour therapy adapted health anxiety or standard care. SETTING Cardiology, endocrine, gastroenterology, neurological and respiratory clinics in six general hospitals in the UK covering urban, suburban and rural areas. PARTICIPANTS Medical patients attending the clinics who had pathological health anxiety and also scored for a diagnosis of hypochondriasis. METHODS Patients were randomised to one of two treatment arms, 5-10 sessions of cognitive behaviour therapy adapted health anxiety or standard care delivered by naive therapists (not randomised) who were trained in advance before delivering the treatment. Independent assessment of outcomes by researchers masked to allocation status at 3m, 6m, 12m and 24m. RESULTS 444 patients were randomised in the trial, 219 to cognitive behaviour therapy adapted health anxiety and 225 to standard care. 373 (84%) completed assessments after two years. Those treated by nurses (n=66) had improvement in health anxiety, generalised anxiety and depression outcomes that were significantly better and twice as great as those of the professional groups of assistant psychologists (n=87) and graduate workers (n=66) (P<0.01 over all time points). The number needed to treat to show superiority of nurse-delivered treatment over other treatment delivery was 4 at 6 months and 6 at one year. CONCLUSION General nurses, after suitable training, are very effective therapists for patients with health anxiety in medical clinics and should be the therapists of choice for patients in these settings.
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Affiliation(s)
- Helen Tyrer
- Centre for Mental Health, Imperial College, Claybrook Road, London W6 8LN, UK
| | - Peter Tyrer
- Centre for Mental Health, Imperial College, Claybrook Road, London W6 8LN, UK.
| | - Yvonne Lisseman-Stones
- Department of Nursing, King's Mill Hospital, Sutton-in-Ashfield, Nottinghamshire NG17 4JL, UK
| | - Sharon McAllister
- Medical Services, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Sylvia Cooper
- Centre for Mental Health, Imperial College, Claybrook Road, London W6 8LN, UK
| | - Paul Salkovskis
- Department of Psychology, University of Bath, Bath BA2 7AY, UK
| | - Michael J Crawford
- Centre for Mental Health, Imperial College, Claybrook Road, London W6 8LN, UK
| | - Simon Dupont
- Greenacres Centre, Hillingdon Hospital, Pield Heath Road, Uxbridge UB8 3NN, UK
| | - John Green
- Central and North West London NHS Foundation Trust, Hampstead Road, London NW1 7QY, UK
| | - David Murphy
- Department of Clinical Psychology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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15
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Hedman E, Andersson G, Lindefors N, Gustavsson P, Lekander M, Rück C, Andersson E, Ljótsson B. Personality change following internet-based cognitive behavior therapy for severe health anxiety. PLoS One 2014; 9:e113871. [PMID: 25437150 PMCID: PMC4250052 DOI: 10.1371/journal.pone.0113871] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 11/02/2014] [Indexed: 11/23/2022] Open
Abstract
Personality traits have traditionally been viewed as stable, but recent studies suggest that they could be affected through psychological treatment. Internet-based cognitive behavior therapy (ICBT) for severe health anxiety (DSM-IV hypochondriasis) has been shown to be effective in reducing health anxiety, but its effect on measures of personality traits has not been investigated. The main aim of this study was to investigate the impact of ICBT on personality traits in the three broad dimensions - neuroticism, extraversion and aggression. We hypothesized that participants in ICBT would reduce their level of neuroticism compared to controls that did not receive the active treatment. No specific predictions were made regarding extraversion and aggression. Data from a randomized controlled trial were used in which participants were allocated to 12 weeks of ICBT (n = 40) or to a basic attention control condition (n = 41). Personality traits were assessed with the Swedish Universities Scales of Personality and the primary outcome of health anxiety was the Health Anxiety Inventory. There was a significant interaction effect of group and time on neuroticism-related scales, indicating larger pre- to post-treatment reductions in the Internet-based CBT group compared to the control condition. Analyses at 6-month follow-up showed that changes were stable. Traits relating to extraversion and aggression were largely unchanged. This study is the first to demonstrate that a brief ICBT intervention for severe health anxiety causes long-term changes in measures of personality traits related to neuroticism. The treatment thus has a broader impact than just reducing health anxiety. Trial Registration Clinicaltrials.gov (ID NCT00828152)
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Affiliation(s)
- Erik Hedman
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Gerhard Andersson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
- Swedish Institute for Disability Research, Linköping University, Linköping, Sweden
| | - Nils Lindefors
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Petter Gustavsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Mats Lekander
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Christian Rück
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
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Veddegjærde KEF, Sivertsen B, Wilhelmsen I, Skogen JC. Confirmatory factor analysis and item response theory analysis of the Whiteley Index. Results from a large population based study in Norway. The Hordaland Health Study (HUSK). J Psychosom Res 2014; 77:213-8. [PMID: 25149031 DOI: 10.1016/j.jpsychores.2014.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/20/2014] [Accepted: 06/22/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Whiteley Index (WI) is a widely used screening instrument for health anxiety/hypochondriasis. Several studies have previously explored the psychometric properties of the WI, but with mixed findings concerning both item composition and factor structure. The main aim of the current study was to examine different factor structures as identified from previous studies using data from a large general population based study. We also wanted to provide gender specific norms. METHODS Data were taken from a large population-based study in Norway, the Hordaland Health Study (HUSK N=7274). Confirmatory factor analysis (CFA) of several models of the WI was conducted. Item response theory (IRT) analysis was performed on the model with the best goodness-of-fit. RESULTS CFA of all previously proposed factor models of the WI revealed clearly inadequate model fits. The IRT analysis suggested that a six-item model best described the data, and CFA confirmed an adequate goodness-of-fit across indices. CONCLUSION The current study found evidence for a six-item, single-factor model of the WI. Our findings suggest that this abbreviated version has the best factor structure compared to previously proposed factor models. We recommend that the factor structure identified in this study should be investigated further in independent samples.
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Affiliation(s)
- Kari-Elise Frøystad Veddegjærde
- Department of Clinical Science, University of Bergen, Bergen, Norway; Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway; Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.
| | - Børge Sivertsen
- Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway; Uni Health, Uni Research, Bergen, Norway; Department of Psychiatry, Helse Fonna HF, Haugesund, Norway
| | - Ingvard Wilhelmsen
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Jens Christoffer Skogen
- Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway; Uni Health, Uni Research, Bergen, Norway; Alcohol and Drug Research Western Norway, Stavanger University, Hospital Stavanger, Stavanger, Norway
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17
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A community-based epidemiological study of health anxiety and generalized anxiety disorder. J Anxiety Disord 2014; 28:187-94. [PMID: 24295847 DOI: 10.1016/j.janxdis.2013.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 10/09/2013] [Accepted: 10/10/2013] [Indexed: 11/20/2022]
Abstract
This community-based study examined the frequency of worry about personal health in respondents with and without generalized anxiety disorder (GAD), and the impact of health anxiety on the disorder. A random community-based telephone survey of 5118 Chinese respondents aged 18-64 was conducted. A fully structured questionnaire covered the DSM-IV-TR criteria of GAD, major depressive episode (MDE), eight domains of worry, the seven-item Whiteley Index (WI-7), health service use, and socio-demographic information. Worry about personal health ranked fifth (75.6%) among eight domains of worries examined. GAD respondents with high level of health anxiety were significantly older, less educated, and had lower family income. High health anxiety significantly increased the occurrence of one-year MDE, previous persistent worry, previous persistent low mood, number of domains of worries, number of non-core DSM-IV-TR GAD symptoms, health service use, and mistrust of doctors. Health anxiety is common in GAD and may signify greater severity of the disorder.
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18
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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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19
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Hedman E, Lekander M, Ljótsson B, Lindefors N, Rück C, Hofmann SG, Andersson E, Andersson G, Schulz SM. Sudden gains in internet-based cognitive behaviour therapy for severe health anxiety. Behav Res Ther 2014; 54:22-9. [PMID: 24468920 DOI: 10.1016/j.brat.2013.12.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 12/20/2013] [Accepted: 12/21/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE A sudden gain is defined as a large and stable individual improvement occurring between two consecutive treatment sessions. Sudden gains have been shown to predict better long-term improvement in several treatment studies, including cognitive behavioural therapy for depression and anxiety disorders, but have not been studied in the treatment of health anxiety or any form of internet-based cognitive behavioural therapy. The aim of this study was to investigate the role of sudden gains in internet-based cognitive behavioural therapy for severe health anxiety. METHOD We examined the occurrence and significance of sudden gains in measures of health anxiety in 81 participants receiving internet-based cognitive behavioural therapy. We compared patients with sudden gains, patients without sudden gains, and patients with gradual gains. RESULTS Thirteen participants (16%) experienced one sudden gain in health anxiety with individual sudden gains distributed across the treatment. As expected, patients with a sudden gain showed larger improvements than patients without a sudden gain at post-treatment (d = 1.04) and at one-year follow-up (d = 0.91) on measures of health anxiety. CONCLUSIONS Consistent with previous studies, sudden gains in internet-based cognitive behavioural therapy are associated with significantly larger and stable treatment effects up to one-year follow-up.
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Affiliation(s)
- Erik Hedman
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
| | - Mats Lekander
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
| | - Nils Lindefors
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
| | - Christian Rück
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
| | | | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
| | - Gerhard Andersson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
| | - Stefan M Schulz
- Department of Psychology I, University of Würzburg, Würzburg, Germany; Comprehensive Heart Failure Center, University of Würzburg, Germany.
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Hedman E, Andersson E, Andersson G, Lindefors N, Lekander M, Rück C, Ljótsson B. Mediators in internet-based cognitive behavior therapy for severe health anxiety. PLoS One 2013; 8:e77752. [PMID: 24147073 PMCID: PMC3798404 DOI: 10.1371/journal.pone.0077752] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 09/05/2013] [Indexed: 11/18/2022] Open
Abstract
According to the cognitive behavioral model of severe health anxiety (hypochondriasis) four central maintaining mechanisms are how the individual perceives the risk of disease and how negative its consequences would be, attention to bodily sensations, and intolerance of uncertainty. The aim of the present study was to investigate the mediating role of these putative mechanisms in Internet-delivered CBT for severe health anxiety. We analyzed data from an RCT where participants were randomized to Internet-delivered CBT (n=40) or to a control condition (n=41). Mediators and outcome, i.e. health anxiety, were assessed weekly throughout the treatment, enabling fulfillment of the criterion of temporal precedence of changes occurring in the mediator in relation to the outcome to be met. The results showed that reduced perceived risk of disease, less attention to bodily symptoms, and reduced intolerance of uncertainty significantly mediated improvement in health anxiety. The study supports the validity of the cognitive behavioral model of health anxiety. The findings have theoretical and clinical implications as they indicate processes that may be causally related to the improvements observed after CBT for health anxiety.
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Affiliation(s)
- Erik Hedman
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Gerhard Andersson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden
| | - Nils Lindefors
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Mats Lekander
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Christian Rück
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
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21
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Skritskaya NA, Carson-Wong AR, Moeller JR, Shen S, Barsky AJ, Fallon BA. A clinician-administered severity rating scale for illness anxiety: development, reliability, and validity of the H-YBOCS-M. Depress Anxiety 2012; 29:652-64. [PMID: 22504935 PMCID: PMC4672371 DOI: 10.1002/da.21949] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 02/28/2012] [Accepted: 03/10/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Clinician-administered measures to assess severity of illness anxiety and response to treatment are few. The authors evaluated a modified version of the hypochondriasis-Y-BOCS (H-YBOCS-M), a 19-item, semistructured, clinician-administered instrument designed to rate severity of illness-related thoughts, behaviors, and avoidance. METHODS The scale was administered to 195 treatment-seeking adults with DSM-IV hypochondriasis. Test-retest reliability was assessed in a subsample of 20 patients. Interrater reliability was assessed by 27 interviews independently rated by four raters. Sensitivity to change was evaluated in a subsample of 149 patients. Convergent and discriminant validity was examined by comparing H-YBOCS-M scores to other measures administered. Item clustering was examined with confirmatory and exploratory factor analyses. RESULTS The H-YBOCS-M demonstrated good internal consistency, interrater and test-retest reliability, and sensitivity to symptom change with treatment. Construct validity was supported by significant higher correlations with scores on other measures of hypochondriasis than with nonhypochondriacal measures. Improvement over time in response to treatment correlated with improvement both on measures of hypochondriasis and on measures of somatization, depression, anxiety, and functional status. Confirmatory factor analysis did not show adequate fit for a three-factor model. Exploratory factor analysis revealed a five-factor solution with the first two factors consistent with the separation of the H-YBOCS-M items into the subscales of illness-related avoidance and compulsions. CONCLUSIONS H-YBOCS-M appears to be valid, reliable, and appropriate as an outcome measure for treatment studies of illness anxiety. Study results highlight "avoidance" as a key feature of illness anxiety-with potentially important nosologic and treatment implications.
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Affiliation(s)
- Natalia A. Skritskaya
- School of Social Work & Department of Psychiatry, Columbia University, New York,Correspondence to: Natalia A. Skritskaya, Ph.D., School of Social Work, Columbia University, 1255 Amsterdam Ave., Room 835, New York, NY 10027.
| | | | | | - Sa Shen
- Department of Psychiatry, Columbia University, New York
| | - Arthur J. Barsky
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts,Department of Psychiatry, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Brian A. Fallon
- Department of Psychiatry, Columbia University, New York,Department of Psychiatry, New York State Psychiatric Institute
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CHAMP: Cognitive behaviour therapy for health anxiety in medical patients, a randomised controlled trial. BMC Psychiatry 2011; 11:99. [PMID: 21672205 PMCID: PMC3141642 DOI: 10.1186/1471-244x-11-99] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 06/14/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Abnormal health anxiety, also called hypochondriasis, has been successfully treated by cognitive behaviour therapy (CBT) in patients recruited from primary care, but only one pilot trial has been carried out among those attending secondary medical clinics where health anxiety is likely to be more common and have a greater impact on services. The CHAMP study extends this work to examine both the clinical and cost effectiveness of CBT in this population. METHOD/DESIGN The study is a randomized controlled trial with two parallel arms and equal randomization of 466 eligible patients (assuming a 20% drop-out) to an active treatment group of 5-10 sessions of cognitive behaviour therapy and to a control group. The aim at baseline, after completion of all assessments but before randomization, was to give a standard simple explanation of the nature of health anxiety for all participants. Subsequently the control group was to receive whatever care might usually be available in the clinics, which is normally a combination of clinical assessment, appropriate tests and reassurance. Those allocated to the active treatment group were planned to receive between 5 and 10 sessions of an adapted form of cognitive behaviour therapy based on the Salkovskis/Warwick model, in which a set of treatment strategies are chosen aimed at helping patients understand the factors that drive and maintain health anxiety. The therapy was planned to be given by graduate research workers, nurses or other health professionals trained for this intervention whom would also have their competence assessed independently during the course of treatment. The primary outcome is reduction in health anxiety symptoms after one year and the main secondary outcome is the cost of care after two years. DISCUSSION This represents the first trial of adapted cognitive behaviour therapy in health anxiety that is large enough to test not only the clinical benefits of treatment but also whether the cost of treatment is offset by savings from reduced use of other health services in comparison to the control group.Cognitive behaviour therapy for Health Anxiety in Medical Patients (CHAMP) TRIAL REGISTRATION: Current Controlled Trials ISRCTN14565822.
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Abstract
Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.
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Affiliation(s)
- A J Barsky
- Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Abstract
Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.
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Affiliation(s)
- A J Barsky
- Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Holder-Perkins V, Wise TN, Williams DE. Hypochondriacal Concerns: Management Through Understanding. Prim Care Companion CNS Disord 2000; 2:117-121. [PMID: 15014644 PMCID: PMC181122 DOI: 10.4088/pcc.v02n0402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2000] [Accepted: 07/19/2000] [Indexed: 10/20/2022] Open
Abstract
The medically unexplained complaint is often a symptom of hypochondriacal concerns. Patients with hypochondriasis may be managed with either naive realism or consideration of morbid categorization or via dimensional assessment of illness beliefs and behaviors. Naive realism will foster focus somatization and promote regression as well as lead to needless tests and treatments. Attention to categorical entities such a major depression or anxiety disorders will alert the clinician to comorbid psychiatric disorders that respond to traditional psychiatric treatments. Finally, by assessing the domains of illness behaviors such as disease conviction, beliefs in organic versus psychological causes, and denial, the clinician can document and then confront abnormal cognitive schema that revolve around somatic concerns that are a proxy for psychosocial difficulties.
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Affiliation(s)
- Vicenzio Holder-Perkins
- Departments of Psychiatry and Behavioral Medicine, Inova Fairfax Hospital, Falls Church, Va., and the Department of Psychiatry, Georgetown University School of Medicine, Washington, D.C
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