CBT effective in treatment of hypochondriasis
Hypochondriasis is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as ‘preoccupation with fears of having, or the idea that one has, a serious disease, based on a misinterpretation of bodily symptoms. This preoccupation must have been present for at least six months and persists despite adequate medical reassurance.'1
Although it is common in primary care (with a prevalence of 2-7%)1, hypochondriasis is often not diagnosed. This is perhaps because of a lack of awareness that it is a condition in its own right (there is partial overlap with both somatisation2 and depression3), or perhaps because of a perception that it is a chronic condition that is refractory to treatment.
A secondary care study has looked at the treatment of a severely affected group of patients with hypochondriasis (mean duration of symptoms 10 years).
The study randomly assigned 112 patients with hypochondriasis to 16 weeks of outpatient treatment with cognitive behaviour therapy (CBT), paroxetine or a placebo. Seventy-five per cent of participants had comorbid psychiatric diagnoses, including 21% with major depression and 40% with panic disorder. Response to treatment was measured using the Whiteley index, a 14-item questionnaire designed to assess the core features of hypochondriasis.
The pooled results for the two treatment groups were significantly better than placebo and there was no significant difference between the results for CBT and paroxetine. The effect sizes in the intention-to-treat cohorts of the interventions were modest (0.44 and 0.40 respectively).
The number of participants in the study was insufficient to compare both treatment groups separately with placebo. Although the CBT specifically targeted hypochondriacal symptoms, it is possible that the benefit from paroxetine arose indirectly from its effect on comorbid anxiety, depression, or other somatoform disorders. Patients were only followed up for 16 weeks: it is likely that long-term outcomes were better in patients treated with CBT.
Several controlled studies have shown CBT to be an effective treatment for hypochondriasis. Patients are helped to identify and modify their dysfunctional beliefs, for example that ‘bodily changes are usually a sign of serious disease, because every symptom has to have an identifiable physical cause.'4
Aetiological factors include previous serious illnesses, especially in childhood, or past experience of disease in a family member; construction of a family tree may provide insight and facilitate brief CBT.
Antidepressants may have a role in treating associated major depression, panic disorder or functional somatic syndromes, but more evidence is required before they can be advocated as a specific treatment for hypochondriasis.
Greeven A, van Balkom AJLM, Visser S et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007;164:91-99reviewerreviewer Reviewer
Dr Phillip Bland