Adaptation of a GAD treatment for hypochondriasis

An examination of the relationship of patient modifiable and non-modifiable characteristics with fear of cancer recurrence among colorectal cancer survivors

PURPOSE

Fear of cancer recurrence (FCR) is one of the most common and distressing issues affecting cancer survivors. This study examined (1) the association between modifiable cognitive, behavioral, and social characteristics and FCR, (2) the association between non-modifiable characteristics and FCR, and (3) the relative contributions of modifiable and non-modifiable characteristics to FCR.

METHODS

Participants (n = 120) had been diagnosed with colorectal cancer and completed cancer treatment in the past 6 to 36 months. Participants completed self-report measures of modifiable cognitive (e.g., beliefs about worry), behavioral (e.g., health-related reassurance seeking), and social (e.g., social constraints) characteristics. Non-modifiable characteristics (e.g., age, disease severity) were assessed via self-report and medical record review.

FINDINGS

Modifiable (i.e., perceived risk, self-efficacy, positive beliefs about worry, negative beliefs about worry, intolerance of uncertainty, rumination, reassurance seeking, health-related reassurance seeking, social constraints) and non-modifiable (i.e., age, gender, disease severity, neuroticism, conscientiousness) characteristics were associated with FCR (p's < .05). Hierarchical linear regression analyses demonstrated that modifiable characteristics accounted for an additional 15% of the variance (p < .001) beyond that accounted for by non-modifiable characteristics (R² = .45, p < .001), with perceived risk (B = .35) and health-related reassurance seeking (B = .22) emerging as significant predictors of FCR (p's < .05).

IMPLICATIONS

Results identify non-modifiable characteristics that may serve as risk factors for greater FCR and identify specific modifiable characteristics (i.e., perceived risk, health-related reassurance seeking) to be targeted by interventions to reduce FCR among cancer survivors.

A review of the relationship between intolerance of uncertainty and threat appraisal in anxiety

The development and conceptual relationship of the constructs of threat appraisal (TA) and intolerance of uncertainty (IU) are explored in the context of anxiety disorders. A narrative review tracking the development of these constructs and their relationship is undertaken. There is some evidence to suggest that the interaction between the components of threat appraisal (probability × cost) may partially account for or provide a theoretical framework which explains presenting levels of anxiety. Furthermore, research suggested that IU is a construct which contributes to a broad range of anxiety disorders. It was concluded that distinctive cognitive biases linked with IU – such as interpreting ambiguous and uncertain (both positive and negative) information as highly concerning – suggests that IU is interpreted negatively independent of threat appraisal. These findings mean a number of issues remain unclear, including whether IU in anxiety-provoking situations is sufficient in itself – independent of threat appraisal – in eliciting high levels of anxiety. Additionally, it is unclear whether threat appraisal and IU act as independent constructs, or more in an interactive manner in anxiety. To achieve further clarity on these issues, methodological recommendations for future research are made.

Key learning aims

(1)

Towards the validation of a new, blended theoretical model of fear of cancer recurrence

OBJECTIVE

Fear of cancer recurrence (FCR) is defined as "fear, worry, or concern about cancer returning or progressing". To date, only the seminal model proposed by Lee-Jones and colleagues has been partially validated, so additional model testing is critical to inform intervention efforts. The purpose of this study is to examine the validity of a blended model of FCR that integrates Leventhal's Common Sense Model, Mishel's Uncertainty in Illness Theory, and cognitive theories of worry.

METHODS

Participants (n = 106) were women diagnosed with stage I to III breast or gynecological cancer who were enrolled in a Randomized Controlled Trial of a group cognitive-existential intervention for FCR. We report data from standardized questionnaires (Fear of Cancer Recurrence Inventory-Severity and Triggers subscales; Illness Uncertainty Scale; perceived risk of recurrence; Intolerance of Uncertainty Scale; Why do people Worry about Health questionnaire; Reassurance-seeking Behaviors subscale of the Health Anxiety Questionnaire, and the Reassurance Questionnaire) that participants completed before randomization. Path analyses were used to test the model.

RESULTS

Following the addition of four paths, the model showed an excellent fit (χ2 = 13.39, P = 0.20; comparative fit index = 0.99; root mean square error of approximation = 0.06). Triggers, perceived risk of recurrence, and illness uncertainty predicted FCR. FCR was associated with maladaptive coping. Positive beliefs about worrying and intolerance of uncertainty did not predict FCR but led to more maladaptive coping.

CONCLUSIONS

These results provide support for a blended FCR model.

Intolerance of Uncertainty in eating disorders: An update on the field

Pathological fear and anxiety regarding food, eating, weight and body shape are at the core of eating disorder (ED) psychopathology. To manage anxiety, patients develop complicated repertoires of ritualistic and repetitive behaviours, which can lead to total functional impairment. Yet the cognitive processes underlying anxiety, fear, and anxiety-driven behaviours in EDs remain poorly understood. Intolerance of Uncertainty (IU) is defined as a tendency to react negatively on an emotional, cognitive, and behavioural level to uncertain situations and events. There is substantial evidence that IU is a transdiagnostic process that contributes to the maintenance of anxiety disorders; however, IU may also be relevant to the understanding and treatment of EDs. The current review summarises the growing literature examining IU in relation to ED symptoms, including restriction, bingeing, purging, ritualised behaviours, reassurance-seeking and body checking. Extending from the obsessive-compulsive disorder (OCD) and anxiety disorder literature, we propose that IU provides a novel theoretical and clinical framework from which to understand the anxiety, fixation with rules and rituals, and the cognitively rigid profile that is characteristic of ED presentations. We conclude with suggestions for future research, and discuss IU as a potential treatment target for core features of EDs and comorbid symptoms.

Screening for psychological distress in very long-term adult survivors of childhood cancer

This study evaluated the prevalence of psychological distress (PD) in a cohort of 348 adult childhood cancer survivors with a very long-term follow-up and assessed the characteristics associated with this distress (cancer type, treatment, sex, age at diagnosis, self-reported late effects, social support, type of remembrance, time since the diagnosis, age at evaluation), assuming that with time since the diagnosis, the PD of survivors will approximate that of the general population. Before attending a long-term follow-up consultation, survivors were sent 3 questionnaires: the Brief Symptom Inventory-18, the Impact of Event Scale, and the Illness Worry Scale (IWS). During the visit, they were administered the Mini-International Neuropsychiatric Interview (MINI) by a psychologist. The mean age of the survivors was 38.5 years (18.1-65.8) at consultation, 7 years (0.0-18.0) at cancer diagnosis, and mean time since diagnosis was 31.5 years (8.8-56.1). Multiple regression analyses of the data collected from self-administered questionnaires confirmed that being female, living alone, and self-reported late effects were associated with the high scores for all scales. Negative remembrances and being accompanied to the clinic were associated with higher IWS scores. Unlike the initial hypothesis, the MINI showed that, compared with controls, survivors experienced a higher prevalence of anxiety and mood disorders even after a very long time since the diagnosis. These findings show that a substantial subset of survivors experiment a high prevalence of PD, higher than the general population, and should be screened for PD whatever the time since the diagnosis.

Intolerance of uncertainty in emotional disorders: What uncertainties remain?

The current paper presents a future research agenda for intolerance of uncertainty (IU), which is a transdiagnostic risk and maintaining factor for emotional disorders. In light of the accumulating interest and promising research on IU, it is timely to emphasize the theoretical and therapeutic significance of IU, as well as to highlight what remains unknown about IU across areas such as development, assessment, behavior, threat and risk, and relationships to cognitive vulnerability factors and emotional disorders. The present paper was designed to provide a synthesis of what is known and unknown about IU, and, in doing so, proposes broad and novel directions for future research to address the remaining uncertainties in the literature.

Intolerance of uncertainty in body dysmorphic disorder

Intolerance of uncertainty (IU) is a transdiagnostic construct associated with several anxiety and related disorders. Three studies were conducted to explore the potential relationship between IU and body dysmorphic disorder (BDD). Study 1 revealed a positive relationship between IU and BDD symptoms above symptoms of anxiety and depression in an unselected student sample (N=88). Study 2 demonstrated a similar relationship between IU and BDD symptoms above negative affectivity and intolerance of ambiguity in a community sample (N=116). Study 3 found that a clinical BDD sample (N=23) reported greater IU than healthy controls (N=20), though this relationship was accounted for by symptoms of anxiety and depression. Greater IU predicted functional impairment in the clinical sample above BDD symptoms and past-week anxiety and depression. The observed relationship between IU and BDD symptoms provides preliminary support for the relevance of IU to this population.

Examining the Specific Facets of Distress Tolerance That Are Relevant to Health Anxiety

Researchers have called for examinations of associations between distinct facets of distress tolerance and specific forms of psychopathology. We examined associations between five facets of distress tolerance (intolerance of uncertainty, ambiguity, frustration, negative emotion, and physical discomfort) and health anxiety using a large community sample of adults. Structural equation modeling was used to examine associations. Intolerance of uncertainty, negative emotion, and physical discomfort were the only facets of distress tolerance that shared unique associations with health anxiety after accounting for the overlap among the facets of distress tolerance. Intolerance of physical discomfort shared an especially strong unique association with health anxiety. These results highlight facets of distress tolerance that are particularly relevant to health anxiety. Conceptual and therapeutic implications are discussed.

How do elements of a reduced capacity to withstand uncertainty relate to the severity of health anxiety?

Intolerance of uncertainty (IU)--a multidimensional cognitive vulnerability factor--is associated with a variety of anxiety disorders and health anxiety (HA). To date, few studies have assessed whether IU dimensions (prospective and inhibitory IU) are differentially associated with HA and whether their contributions are independent of anxiety sensitivity (AS). This study addressed these issues using independent community (n = 155; 81% women) and undergraduate (n = 560; 86% women) samples. Results indicated that prospective IU, but not inhibitory IU, had significant positive associations with HA in community dwellers and undergraduate students. AS somatic and cognitive concerns were also significant predictors among both samples. In addition, severity of IU dimensions among individuals reporting elevated HA were compared against individuals diagnosed with generalized anxiety disorder, social anxiety disorder, panic disorder, and obsessive-compulsive disorder. Results indicated minimal differences between those with elevated HA and each of the anxiety disorder diagnoses. Findings lend support to the unique transdiagnostic nature of IU and support commonalities between HA and anxiety disorders.

Addressing fear of cancer recurrence among women with cancer: a feasibility and preliminary outcome study

BACKGROUND

Evidence suggests that fear of cancer recurrence (FCR) is one of the most frequently cited unmet needs among cancer survivors and is associated with psychological distress, stress-response symptoms, and lower quality of life, as well as increased use of health care resources. Despite these factors, few manualized interventions exist to address FCR among cancer survivors.

PURPOSE

To develop, manualize, and pilot test the feasibility and preliminary efficacy of a 6-week cognitive-existential (CE) group intervention designed to address FCR in women with breast or ovarian cancer.

METHODS

This study was a single-arm multi-site study with pre-, post-, and 3-month follow-up measurement occasions.

RESULTS

A total of 56 breast or ovarian cancer survivors enrolled in the study; 44 completed the CE group intervention. Following the intervention, women experienced a reduction in the primary study outcome measure of FCR and secondary study outcome measures of cancer-specific distress and uncertainty. They also reported improvements in secondary study outcome measures of quality of life and coping. The effect sizes of the observed changes were for the most part in the medium to large effect range; furthermore, almost all changes were sustained at 3-month follow-up.

CONCLUSION

This brief intervention appears feasible and has shown promising results in addressing FCR and related secondary outcomes of cancer-specific distress, uncertainty, quality of life, and coping; however, it should be further tested using a randomized controlled study design to more definitively assess its efficacy.

IMPLICATIONS FOR CANCER SURVIVORS

FCR is a near-universal worry for cancer survivors that, when left unaddressed, tends to remain stable over time. This study has important implications for all cancer survivors as it is the first published intervention that provides preliminary evidence of its efficacy in decreasing fear of cancer recurrence.

A transdiagnostic examination of intolerance of uncertainty across anxiety and depressive disorders

Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective and inhibitory IU) have been shown to be differentially associated with symptoms of emotional disorders. The aim of this study was to determine the extent to which individuals with various anxiety and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory components) and secondly in reference to regularly occurring, diagnostically relevant situations (situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly comorbid clinical sample (N=218). Regardless of specific diagnoses, the degree of comorbidity emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical practice.

Emotional distress impacts fear of the future among breast cancer survivors not the reverse

INTRODUCTION

Fear of the future is one of the most stressful aspects of having cancer. Research to date has conceptualized fear of the future as a precursor of distress or stress-response symptoms. Yet it is equally plausible that distress would predict increased fear of the future or that they would have a reciprocal influence on each other. The purpose of the present study was to examine the bidirectional relations between fear of the future and distress as well as intrusion and avoidance among breast cancer survivors at 3, 7, 11, and 15 months after diagnosis.

METHODS

We used a bivariate latent difference score model for dynamic change to examine these bidirectional relationships among 146 early-stage breast cancer survivors. Using Lisrel version 8.80, we examined four models testing different hypothesized relationships between fear of the future and distress and intrusion and avoidance.

RESULTS

Based on model fit evaluation, our data shows that decreases in distress over time lead to a reduction of fear of the future but that changes in fear do not lead to changes in distress. On the other hand, there is no relationship between changes in fear of the future and intrusion and avoidance over time.

DISCUSSION

Ongoing fear of the future does not appear to be a necessary condition for the development of stress-response symptoms.

IMPLICATIONS FOR CANCER SURVIVORS

Future studies need to explore the role of distressing emotions in the development and exacerbation of fear of the future among cancer survivors.

Psychotherapies for hypochondriasis

BACKGROUND

Hypochondriasis is associated with significant medical morbidity and high health resource use. Recent studies have examined the treatment of hypochondriasis using various forms of psychotherapy.

OBJECTIVES

To examine the effectiveness and comparative effectiveness of any form of psychotherapy for the treatment of hypochondriasis.

SEARCH STRATEGY

1. CCDANCTR-Studies and CCDANCTR-References were searched on 7/8/2007, CENTRAL, Medline, PsycINFO, EMBASE, Cinahl, ISI Web of Knowledge, AMED and WorldCat Dissertations; Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register and clinicaltrials.gov; 2. Communication with authors of relevant studies and other clinicians in the field; 3. Handsearching reference lists of included studies and relevant review articles, and electronic citation search in ISI Web of Knowledge for all included studies.

SELECTION CRITERIA

All randomised controlled studies, both published and unpublished, in any language, in which adults with hypochondriasis were treated with a psychological intervention.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors using a standardised extraction sheet. Study quality was assessed independently by the two authors qualitatively and using a standardised scale. Meta-analyses were performed using RevMan software. Standardised or weighted mean differences were used to pool data for continuous outcomes and odds ratios were used to pool data for dichotomous outcomes, together with 95% confidence intervals.

MAIN RESULTS

Six studies were included, with a total of 440 participants. The interventions examined were cognitive therapy (CT), behavioural therapy (BT), cognitive behavioural therapy (CBT), behavioural stress management (BSM) and psychoeducation. All forms of psychotherapy except psychoeducation showed a significant improvement in hypochondriacal symptoms compared to waiting list control (SMD (random) [95% CI] = -0.86 [-1.25 to -0.46]). For some therapies, significant improvements were found in the secondary outcomes of general functioning (CBT), resource use (psychoeducation), anxiety (CT, BSM), depression (CT, BSM) and physical symptoms (CBT). These secondary outcome findings were based on smaller numbers of participants and there was significant heterogeneity between studies.

AUTHORS' CONCLUSIONS

Cognitive therapy, behavioural therapy, cognitive behavioural therapy and behavioural stress management are effective in reducing symptoms of hypochondriasis. However, studies included in the review used small numbers of participants and do not allow estimation of effect size, comparison between different types of psychotherapy or whether people are "cured". Most long-term outcome data were uncontrolled. Further studies should make use of validated rating scales, assess treatment acceptability and effect on resource use, and determine the active ingredients and nonspecific factors that are important in psychotherapy for hypochondriasis.

Health anxiety, hypochondriasis, and the anxiety disorders

Although clinical observations suggest that health-related anxiety is present, to some extent, in a number of anxiety disorders, this relationship has not been examined empirically. The present study therefore utilized the Short Health Anxiety Inventory (SHAI) to elucidate the structure of such symptoms among patients with anxiety disorders and to empirically investigate the presence of health anxiety in various anxiety disorders. Confirmatory factor analysis yielded equivalent support for either a 2-factor or 3-factor model of the SHAI's latent structure. The measure demonstrated good reliability, convergent validity, and discriminant validity. Comparison of SHAI scores across groups of patients with various anxiety disorders revealed elevated levels of health anxiety among patients with hypochondriasis and panic disorder relative to those with other anxiety disorders. Receiver operating characteristic analyses supported the utility of the SHAI as a diagnostic tool for screening patients with hypochondriasis utilizing empirically derived cut scores. Findings are discussed in terms of cognitive-behavioral models of anxiety disorders.