treatment preference in hypochondriasis

Journal of Behavior Therapyand Experimental Psychiatry 30 (1999) 251}258

Treatment preference in hypochondriasis

John Walker!,*, Norah Vincent!, Patricia Furer!, Brian Cox",Kevin Kjernisted"

!Department of Clinical Health Psychology, University of Manitoba, Canada"Department of Psychiatry, University of Manitoba, Canada

Abstract

Promising cognitive-behavioral and medication treatments for hypochondriasis are in theearly stages of evaluation. Little is known about the treatment preferences and opinions ofindividuals seeking help for this problem. In this exploratory study, 23 volunteers from thecommunity with a DSM-IV diagnosis of hypochondriasis were recruited through a newspaperadvertisement. Participants were presented with a survey which included balanced descriptionsof both a medication and a cognitive-behavioral treatment for intense illness concerns (hypo-chondriasis). The brief descriptions of the treatments discussed the time commitment requiredas well as the major advantages and disadvantages of each. Results showed that, relative tomedication treatment, cognitive-behavioral treatment was predicted to be more e!ective inboth the short and long terms and was rated as more acceptable. Psychological treatment wasindicated as the "rst choice by 74% of respondents, medication by 4%, and 22% indicated anequal preference. Forty-eight percent of respondents would only accept the psychologicaltreatment. ( 2000 Elsevier Science Ltd. All rights reserved.

Keywords: Hypochondriasis; Treatment preference; Treatment acceptability

1. Introduction

Epidemiologic data indicate that the prevalence of hypochondriasis among medicaloutpatients ranges from 4.2 to 7.7% (Barsky, Wyshak, Klerman, & Latham, 1990;Kirmayer & Robbins, 1991). Individuals with hypochondriasis are more likely to usehealth services, and therefore represent a signi"cant cost to the healthcare system(Noyes, Kathol, Fisher, Phillips, Suelzer, & Woodman, 1994; Palsson, 1988; Pilowsky,

*Correspondence address. Anxiety disorders Program, M5-St. Boniface General Hospital, 409 TacheAve., Winnipeg, MB Canada R2H 2A6. Tel.: #204-237-2335; fax: #204-237-6264.

E-mail address: [email protected] (J. Walker)

0005-7916/00/$ - see front matter ( 2000 Elsevier Science Ltd. All rights reserved.PII: S 0 0 0 5 - 7 9 1 6 ( 9 9 ) 0 0 0 2 7 - 0

Smith, & Katsikitis, 1987). Recently, promising pharmacological (Fallon et al., 1996)and psychological treatments (Clark et al., 1998) have been developed to treatindividuals with hypochondriasis. Little is known, however, about the treatmentpreferences of persons seeking help for this problem or for other mental healthproblems. The form of treatment o!ered may depend more on the training andexperience of the service provider and on the availability of service than on thepreferences of the consumer. In recent years, there has been a growing interest inproviding better information to patients about the available treatments for commonhealth problems and in involving patients more actively in treatment decision making(Llewellyn-Thomas, 1995; Rosenfeld, White, & Passik, 1997; Street & Voigt, 1997).

To date there have been few studies evaluating preference for treatment for com-mon mental health problems in a context in which the respondents are providedinformation about treatment alternatives (Morin, Gaulier, Barry, & Kowatch, 1992;Norton, Allen, & Walker, 1985; Wills & Moore, 1994). Hofmann et al. (1998) reportdata which provide an interesting indirect indication of preference for treatment ofpanic disorder. Their group recruited for a large-scale study of treatment whichinvolved comparing CBT (panic control therapy), pharmacotherapy (imipramine),combined therapy, or placebo control. One center was involved which had a strongreputation for psychopharmacological treatment (Long Island Hospital, NY) and theother was known for cognitive-behavioral treatment of anxiety (Albany, NY). Indi-viduals who were seen in the clinic and met the criteria for the study were invited toparticipate. Those who declined were asked an open-ended question about theirreason for not participating. The most common reason for declining participation wasan unwillingness to take the active medication (31% in Long Island, 47% in Albany).Smaller numbers indicated an unwillingness to take the placebo (3% in Long Island,2% in Albany) or to participate in panic control therapy (0.5% in Long Island, 0% inAlbany). Morin et al. (1992) recruited 39 older adults for treatment of chronic insomniathrough newspaper advertising and 32 signi"cant others of the individuals with insom-nia. They found a much higher rating of acceptance of treatment for behavioraltreatment (75 on a 100 point visual analogue scale) than for pharmacologic treatment(31 on the scale) even when the treatments were described as being equally e!ective.Preference did not di!er between individuals with insomnia and signi"cant others.

The current study explored preference for treatment among individuals seekinghelp for hypochondriasis. It took advantage of a unique opportunity in whichindividuals with hypochondriasis were being recruited simultaneously for studies ofmedication treatment and cognitive behavioral treatment. Typically psychologicaland pharmacological studies are carried out in di!erent settings or in the same settingat di!erent times.

2. Method

2.1. Participants

Participants were 23 volunteers (19 women, 4 men) from the community withhypochondriasis (M age"47 yr, SD"13.1). All were Caucasian and the majority

252 J. Walker et al. / J. Behav. Ther. & Exp. Psychiat. 30 (1999) 251}258

(83%) were married. Participants were relatively well educated, with 78% havinggraduated from high school, and 48% having had post-secondary training rangingfrom a community college/nursing degree to a post-graduate degree. Scores on theWorries about Illness sub-scale (WI) of the illness attitudes scales (IAS; Kellner,Abbott, Pathak, Winslow, & Umland, 1983) (M"10.5 SD"2.9) and scores on theBeck depression inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961)(M"17.6 SD"8.6) were typical of those obtained in outpatients with hypochon-driasis (Barsky, Wyshak, & Klerman, 1986; Kellner, Abbott, Winslow, & Pathak,1987). Many of the participants had received previous specialized testing to investi-gate health complaints. Tests conducted included chest X-ray (78%), EKG (74%),thyroid testing (65%), treadmill stress test (30%), echocardiogram (26%), Holtermonitor (26%), MRI (9%), thallium scan (4%), and others (30%). Many had currentsecondary comorbid diagnoses, which included social phobia (52%), panic disorder(48%), generalized anxiety disorder (30%), and obsessive compulsive disorder (4%).Of participants, 48% (11) were currently taking psychotropic medications (in mostcases a low PRN dose of a benzodiazepine or a relatively low dose of an SSRIantidepressant) and another 17% (4) had previously received medication. Four (17%)were receiving some form of current psychosocial treatment and "ve (22%) hadpreviously received psychological treatment. Previous psychological treatment wasoften focused on problems with panic disorder or depression.

2.2. Materials and procedure

An advertisement in a local newspaper described a study of the treatment of`Intense Illness Worriesa. The advertisement asked questions which paralleled theDSM-IV criteria for hypochondriasis (e.g., Do you fear that you have a seriousmedical illness (such as cancer or heart disease) that doctors have missed? Do otherssay you worry about your health too much?). Over the course of 3 months, 69 peoplecontacted the research coordinator about the study. An information sheet mailed toall potential participants indicated that two treatments (one a medication treatmentand the other a psychological treatment) would be available, however no otherinformation was given about these treatments. A telephone screening interview of15}40 min duration was arranged for respondents who indicated an interest in thestudy. Of those screened, 39% (27) did not meet study criteria for primary hypochon-driasis, 9% (6) met criteria for the study but declined to participate due to di$cultytraveling to the clinic, 10% (7) were not interested in treatment which focused onameliorating illness worrying, and 6% (4) could not be reached by telephone and didnot return telephone calls. Suitable and interested individuals were invited for anin-person interview. Just before the interview, participants completed a survey oftreatment preference for the problem of intense illness worries. The survey includedbrief descriptions of the two treatments including the advantages and disadvantagesof each (see the appendix). The descriptions were parallel in content and similar inlength, and described the treatments as they would be carried out in optimal circum-stances. The descriptions were reviewed by sta! with expertise in pharmacologicaltreatment and cognitive-behavioral treatment and found to be accurate and unbiased.

J. Walker et al. / J. Behav. Ther. & Exp. Psychiat. 30 (1999) 251}258 253

Surveys were completed before participants indicated which treatment study theywished to participate in and before the treatment choices were discussed with theresearch coordinator. The treatment descriptions and rating scales were counter-balanced to reduce the likelihood of an order e!ect. Following completion of thesurvey, a modi"ed version of the Structured Clinical Interview for DSM-IV (SCID)was administered to establish DSM-IV diagnoses (Spitzer, Williams, Gibbon, &First, 1990). Only the data for the 23 individuals who met DSM-IV criteria forhypochondriasis are presented here.

3. Results

Table 1 describes mean responses to ratings of the `acceptability and probablee!ectiveness of each treatment for youa. Results show that psychological treatment(CBT) was rated as more acceptable than pharmacological treatment, and predictedto be more e!ective in the long and short term. After providing ratings of acceptabilityand probable e!ectiveness of the treatments, respondents were asked to rank thetreatments in terms of which one they most preferred. Participants were requested toindicate a "rst and second choice of treatments. If they preferred not to have one ofthe treatments they were asked not to give a rank for that treatment. Respondentswere also given an opportunity to indicate if they had no speci"c preference betweenthe two treatments. When asked to indicate their "rst-choice of preference fortreatment, 74% chose psychological treatment, 4% selected medication, and 22%indicated an equal preference. Eleven individuals (48% of the respondents) would onlyaccept the psychological treatment.

At the time of initial assessment, respondents were grouped into those who werecurrently receiving medication treatment (N"11) and those who were not (N"12).There were no signi"cant di!erences between the groups in ratings predictingthe short-term (t(21)"!0.94, p"0.36) or the long-term (t(18)"0.86, p"0.40)

Table 1Mean ratings of acceptability and probable e!ectiveness of treatments for intense illness worries (hypochon-driasis)!

Question Medicationtreatment

Cognitive-behavioraltreatment

t-value P E!ect size"

M (SD) M (SD)

Acceptability of treatment 3.1 (2.9) 7.0 (1.3) 5.88 0.001 1.23Short-term e!ectiveness 3.4 (2.4) 5.5 (2.1) 2.9 0.01 0.61Long-term e!ectiveness 3.4 (2.8) 7.0 (1.2) 5.44 0.001 1.13

!Note: Scores range from 1 (not at all acceptable/e!ective) to 8 (very acceptable/e!ective). All t-tests aretwo-tailed, df"22.

"E!ect sizes were derived using Cohen's d for correlated samples (Rosenthal, 1994).


e!ectiveness of CBT or short-term (t(21)"0.91, p"0.12) or the long-term (t(21)"!0.04, p"0.97) e!ectiveness of medication. Also, there were no signi"cant di!er-ences between these two groups in the overall acceptability of either CBT(t(21)"0.81, p"0.43) or medication (t(21)"0.58, p"0.57). Thus, current medica-tion treatment did not appear to be related to preferences for cognitive-behavioral ormedication treatments. The sample sizes of these two groups were small, however, sothe "nding of no signi"cant di!erences between the group should be interpreted withcaution.

4. Discussion

Respondents in this exploratory study had a strong preference for psychologicaltreatment. This "nding is consistent with earlier reports which suggest a preferencefor psychological treatments of insomnia (Morin et al., 1992) and panic disorder(Hofmann et al., 1998). This preference stands in contrast to the higher degree ofavailability of pharmacological treatment for these disorders in most communities inNorth America. Increasing the availability of e!ective psychological treatments (suchas CBT for a variety of disorders) may increase treatment adherence and satisfaction.While only limited data are available comparing the cost of psychological andpharmacological treatments (for example, Antonuccio, Thomas, & Danton, 1997 ontreatment of depression), most studies of this type suggest that psychological treat-ments of common disorders are less costly than pharmacological treatments in the"rst year with the di!erence in cost increasing over time. Increasing the availability ofe!ective psychological treatments may decrease costs to the consumer and to healthcare systems.

It is desirable to have a variety of di!erent e!ective treatments available from whichconsumers and providers may choose. In order to make informed decisions, con-sumers require information about the treatments available for their problem and theadvantages and disadvantages of each. The treatment descriptions provided to par-ticipants in this study before they made their ratings were relatively brief and it couldbe argued that consumers require more extensive information, including informationabout cost of treatment and frequency of side e!ects, in order to make more informeddecisions. The "eld would bene"t from the development of high quality and balancedinformational materials to inform consumers of treatments available for commonmental health problems. To this point information sources for consumers are verylimited.

The "ndings of this study are limited to some degree by the relatively small size ofthe sample. However, our center is known for its involvement in research with bothpharmacological and with psychological treatments of anxiety problems. This mayhave reduced the likelihood that respondents expected that they were approachinga clinic which emphasized their preferred method of treatment. Regardless, gatheringinformation from a larger sample would allow for further exploration of demographic(gender, age, education) and experiential (previous treatment experience, symptomseverity) factors related to treatment preference. It would also be useful to explore in


more depth the reasons for treatment preference and to investigate treatment prefer-ences for other clinical problems.

Appendix A. Treatment description for preference survey

A.1. Medication treatment

This treatment is provided by a psychiatrist or a family doctor who providesinformation about intense illness worries, how they develop, and how they are treated.The medication is started at a low dose and then gradually increased until the worriesare signi"cantly reduced. As people feel better they are encouraged to resume theirnormal activities. It is important to take the medication regularly as prescribed* notjust when feeling anxious or worried. The medication usually takes several weeks toproduce some improvement but often people feel reassured just to be startingtreatment.

Duration of treatment. Usually appointments are scheduled weekly initially, andthen appointments are scheduled less frequently for a total of approximately eightappointments. Once the illness worries are reduced or eliminated the medication isusually continued for at least six months.

Advantages. (a) The treatment has been found to be e!ective with many persons,(b) the treatment may be prescribed by your family doctor so it is usually quickly andconveniently arranged, (c) for many people, the medication can be taken once a dayrather than several times a day, (d) if the person also has problems with depression,the medication can help with this problem also, and (e) the medication is not habit-forming.

Disadvantages. (a) The medication sometimes has side e!ects. Often these wear o!after the "rst weeks on the medication, (b) women should not become pregnant whentaking this medication.

A.2. Psychological treatment

This treatment (called cognitive behavior therapy) is usually provided by apsychologist or a behavior therapist who provides information about intense illnessworries, how they develop, and how they are treated. In the early part of thetreatment, the person receiving the treatment gathers information about when andhow illness worries arise in everyday life. Then, the person learns strategies tocope with negative thoughts and worries, to face fears about illness, and not to dothings that increase illness worries. The treatment usually takes several weeks toproduce some improvement but often people feel reassured just to be startingtreatment.

Duration of treatment. The treatment typically lasts for about 10 one-hour sessions* "rst once a week and later less frequently. Once the illness worries are reduced oreliminated, the person is encouraged to continue to work on the coping methods fora number of months.


Advantages. (a) The treatment has been found to be e!ective with many persons,(b) the treatment can be tailored to the person's speci"c problems and experiences,(c) at times it is possible to work on other life problems and goals, (d) if the personalso has problems with depression the treatment can help with this problem also, and(e) the person can apply coping strategies learned in treatment to other problems inthe future.

Disadvantages. (a) This approach takes considerable time and e!ort, (b) duringsome parts of the program, individuals may experience more anxiety as they learn toface worries which are di$cult for them.

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treatment preference in hypochondriasis

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