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Mindfulness-based cognitive therapy for hypochondriasis, or severe health anxiety: A pilot study
Journal of Anxiety Disorders 24 (2010) 931–935
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Journal of Anxiety Disorders
Mindfulness-based cognitive therapy for hypochondriasis, or severe health anxiety: A pilot study David A. Lovas a,b,c,∗ , Arthur J. Barsky a,1 a b c
Department of Psychiatry, Harvard Medical School, Boston, MA, United States Cambridge Health Alliance, Cambridge, MA, United States Massachusetts General Hospital, Boston, MA, United States
a r t i c l e
i n f o
Article history: Received 24 November 2009 Received in revised form 18 June 2010 Accepted 19 June 2010 Keywords: Hypochondriasis Health Anxiety Cognitive therapy Mindfulness
a b s t r a c t In spite of the existence of evidence-based treatments for hypochondriasis, or severe health anxiety, recovery rates are low and morbidity is high. Therefore, more treatment options are needed for this prevalent condition. Mindfulness-based cognitive therapy (MBCT) interventions have been gaining research and clinical attention for the treatment of mood, and more recently anxiety disorders. A small, uncontrolled pilot study of an 8-week group MBCT intervention for hypochondriasis was conducted. Ten subjects (five females and five males) with a mean age of 35.6 (range = 25–59) recruited from an academic community health network met criteria and completed the study. There were significant improvements in measures of health anxiety, disease-related thoughts, somatic symptoms, and mindfulness at the end of treatment, and these benefits were sustained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no drop-outs or adverse events. These findings provide the basis for a larger, more rigorous, controlled trial of this promising treatment approach. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Researchers have been increasingly conceptualizing health anxiety as existing on a spectrum (Abramowitz & Braddock, 2008; Taylor & Asmundson, 2004). On the mild end, it is an adaptive signal that helps to promote survival-oriented behaviors. However, in the case of severe health anxiety, or hypochondriasis, as it is defined in the DSM-IV-TR (APA, 2000), benign bodily sensations trigger anxiety that reaches a dysfunctional level in which fears and beliefs persist in spite of medical reassurance to the contrary. This can in turn lead to maladaptive checking and reassuranceseeking behaviors, which, at their worst, can be associated with iatrogenic harm. Hypochondriasis affects approximately 5% of primary care patients (Barsky, Wyshak, & Klerman, 1990; Faravelli et al., 1997), and is associated with significant impairment (Mykletun et al., 2009). Although there are several large randomized control trials (RCT) demonstrating the efficacy of cognitive behavioral therapy (CBT) and selective-serotonin reuptake inhibitor antidepressants (Barsky & Ahern, 2004; Clark et al., 1998; Greeven et al., 2007), a recent systematic review revealed that the recovery rate
∗ Corresponding author. Present address: Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, YAW 6A, Boston, MA 02114, United States. Tel.: +1 617 724 6300; fax: +1 617 726 9136. E-mail address: [email protected] (D.A. Lovas). 1 Present address: Massachusetts General Hospital, United States. 0887-6185/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2010.06.019
from hypochondriasis is only 30–50% (olde Hartman et al., 2009), and drop out rates from treatment are as high as 25% (Greeven et al., 2007). Thus, more treatment options are needed. The majority of CBT interventions for hypochondriasis are based on an empirically grounded cognitive-perceptual model of the disorder (e.g., Abramowitz, Schwartz, & Whiteside, 2001; Taylor & Asmundson, 2004). This model postulates that patients with significant health anxiety hold dysfunctional beliefs about health and misinterpret innocuous bodily sensations as dangerous. This leads to a cascade of anxiety and heightened physiological arousal which creates more symptoms and an intensification of pre-existing ones. Thus, prior CBT interventions have sought to decrease this arousal through relaxation training, and to change dysfunctional beliefs through cognitive restructuring. However, there is evidence that severe health anxiety is associated not only with abnormal beliefs, but also with dysfunctional cognitive processing, including a propensity for attentional biases (Rassin, Muris, Franken, & van Straten, 2008), and for rumination (Marcus, Hughes, & Arnau, 2008). Mindfulness-based cognitive therapy (MBCT) interventions have been gaining research and clinical attention for the treatment of mood (Segal, Williams, & Teasdale, 2002; Teasdale et al., 2000), and more recently, anxiety disorders (Evans et al., 2008). These interventions differ from traditional CBT in that they do not attempt to change dysfunctional beliefs, but rather to change the thought process. Studies have shown that mindfulness-based interventions are associated with decreased ruminative thoughts (Jain
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et al., 2007). Additionally, emerging evidence suggests that mindfulness meditation, the central technique in mindfulness-based interventions, is associated with adaptive changes in attention (Jha, Krompinger, & Baime, 2007), and in areas of the brain associated with interoception (Lazar et al., 2005). Thus, it was hypothesized that MBCT might be a beneficial intervention for patients with hypochondriasis, or severe health anxiety. Specifically, it was hypothesized that teaching MBCT in this population would result in decreased overall hypochondriacal symptoms, with specific reductions in the frequency and believability of health-related ruminations. It was also hypothesized that there would be improvements in quality of life after the intervention. Lastly, it was hypothesized that improvements in the primary outcome measure of health anxiety would be correlated with improvements in mindfulness. 2. Method 2.1. Participants Participants were recruited from an academic community hospital setting via posted notices around the hospital and primary care clinics, and via email announcements to the primary care medicine and psychiatry faculty. A senior psychiatry resident screened interested subjects for inclusion and exclusion criteria using the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). Inclusion criteria were (a) over 18 years of age, (b) English speaking, (c) medical stability, (d) meeting criteria for significant health anxiety, as determined by a mean per item score on the Whiteley Index of greater than 3, and a diagnosis of “hypochondriasis” based on DSM-IV-TR criteria. Consistent with prior MBCT studies of anxiety (Evans et al., 2008), and prior CBT studies of hypochondriasis (e.g., Barsky & Ahern, 2004), the following were set as exclusion criteria: comorbid, current, moderate–severe major depression (as assessed by BDI score); current psychoactive substance abuse or dependence; psychosis; pregnancy; and ongoing, symptom-contingent, disability determinations, workers’ compensation proceedings, or litigation. Suicide risk was assessed by the MINI suicide module, and individuals scoring in the moderate and high range were also excluded. 2.2. Procedure At baseline, end of treatment, and at 3-month follow-up, participants completed self-report measures of health anxiety, disease-related thoughts, somatic symptoms, somatosensory amplification, general anxiety and mood, and quality of life. A measure of mindfulness, the predicted mediator of effect, was also collected. MBCT was administered in a group format with eight 2-h sessions at weekly intervals. The group was led by a senior psychiatry resident who had completed training in MBCT and had several years of clinical experience. The intervention was educational in focus, and was based on the pre-existing models of Mindfulness-Based Stress Reduction (MBSR) and MBCT, by Kabat-Zinn (1990) and Segal et al. (2002), respectively. Participants were taught mindfulness meditation, including body scan, mindful breathing, and mindful movement practices. While these prior models emphasized the theoretical mechanisms underlying stress and depression-relapse, respectively, the current treatment focused on the putative cognitive-perceptual mechanisms involved in the production and maintenance of hypochondriacal symptoms. Each session followed an agenda and highlighted a different element of this model, along with specific formal and informal mindfulness practices. Many experientially learned concepts were generic to all mindfulness interventions,
such as the ability to de-center from one’s thoughts, and realize that “thoughts are just thoughts—not facts”. Other concepts were more specific to hypochondriasis, such as noticing the relationship between the quality of one’s attention – worried attention versus mindful attention – and amplification of symptoms. Most learning was experiential via the mindfulness practices, and the group process facilitated shared experience, discussion, and trouble-shooting regarding the techniques. Participants were provided guided meditation CDs and were asked to practice the formal meditations at least 30 min every day and to record their practice. 2.3. Measures 2.3.1. Whiteley Index (WI) The primary outcome measure was the WI due to its wide use in assessing health anxiety and hypochondriacal attitudes and beliefs. Reliability, validity, and sensitivity to change of this 14-item selfreport questionnaire is well established (Pilowsky, 1967, 1978). Each item was Likert scored from 1 to 5, and participants’ scores are shown as the mean of these 14 ratings, producing a score of 1–5. The Whiteley Index does not have clearly defined clinical cutoffs, but in unpublished data of one of the authors (AJB), it was found that 120 subjects meeting DSM-III-R criteria for hypochondriasis had a mean WI score of 3.3, with a S.D. of 0.7. Therefore, a cut-off score of 3 was chosen as an even number that is within 1 S.D. of the mean, with the aim of providing a sufficiently stringent cut-off to detect a clinically significant population, but not be overly exclusive to limit the sample size. 2.3.2. Health Anxiety Inventory (HAI) The HAI is a 14-item, self-report questionnaire measuring health anxiety that is minimally influenced by presence of major medical illness and has good validity, internal consistency, and reliability (Salkovskis, Rimes, Warwick, & Clark, 2002). Each item was Likert scored from 0 to 3, and participants’ scores are shown as the mean of these 14 ratings, producing a score of 0–3. The additional illness attitude, avoidance, and reassurance-seeking scales within this questionnaire were scored separately, and were not added to the total HAI score, as is customary for this scale. The illness attitude section is composed of 4 items, which were each Likert scored from 0 to 3, and participants’ scores are shown as the mean of these 4 ratings, producing a score of 0–3. The avoidance section is composed of 10 items, which were each Likert scored from 0 to 8, and participants’ scores are shown as the mean of these 10 ratings, producing a score of 0–8. The reassurance-seeking section is composed of 10 items, which were each Likert scored from 0 to 8, and participants’ scores are shown as the mean of these 10 ratings, producing a score of 0–8. The authors are not aware of clinical cut-offs for the HAI. 2.3.3. Hypochondriacal Cognitions Questionnaire (HCQ) Frequency and believability of hypochondriacal thoughts were assessed with the HCQ. It is a self-report questionnaire that asks respondents to rate the frequency of 18 disease-related thoughts on a Likert scale of 1–5. Participants’ scores are shown as the mean of these 18 ratings, producing a score of 1–5. It also asks respondents to rate the believability of these thoughts as a percentage from 0 to 100%, and the scores are shown as the mean of these 18 rating, producing a score of 0–100. The HCQ has been used previously in a large RCT of CBT for hypochondriasis (Barsky & Ahern, 2004). There are no clinical cut-offs for the HCQ. 2.3.4. Patient Health Questionnaire-15 (PHQ-15) PHQ-15 (Kroenke, Spitzer, & Williams, 2002) is a 15-item selfreport measure of the subjective severity of somatic symptoms, with established validity and reliability in somatoform disorder and primary care populations. It has been widely used as an index
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of somatization. Scoring denotes levels of low (6–10), medium (11–15), or high (16–30) somatic symptom severity.
in the primary outcome measure of hypochondriasis, and the change in mindfulness.
2.3.5. Somatosensory Amplification Scale (SSAS) The tendency to amplify benign bodily sensation and experience it as noxious, unpleasant, and alarming was assessed with the 10item SSAS. It has good reliability and validity (Barsky & Wyshak, 1990; Barsky et al., 1990). Each item was Likert scored from 1 to 5, and participants’ scores are shown as the mean of these 10 ratings, producing a score of 1–5. There are no clinical cut-offs for the SSAS.
3. Results
2.3.6. Toronto Alexithymia Scale (TAS) The TAS (Bagby, Parker, & Taylor, 1994) is a widely used 20-item self-report measure of alexithymia—the relative inability to identify and describe emotions. Alexithymia has been found to be an important predisposing personality variable for somatoform disorders, and the TAS has established validity and reliability in these populations. The TAS has established cut-offs for scoring, denoting non-alexithymia (51 or less), possible alexithymia (52–60), and alexithymia (61 and higher). 2.3.7. Beck Anxiety Inventory (BAI) The BAI (Beck & Steer, 1990) is a widely used 21-item selfreport measure of anxiety with high reliability and validity. Scoring denotes levels of minimal (0–7), mild (8–15), moderate (16–25), and severe (25–63) anxiety. 2.3.8. Beck Depression Inventory-II (BDI-II) The BDI-II (Beck, Steer, & Garbin, 1998) is a widely used 21-item self-report measure of depression with well-established psychometric properties and with high reliability and validity. Scoring denotes levels of minimal (0–13), mild (14–19), moderate (20(28), and severe (29–63) depression.
3.1. Demographic characteristics Of the 18 subjects who were screened for the study, 10 met inclusion criteria and participated in the study. Seven subjects were excluded due to subthreshold scores on the primary outcome measure at screening (Whiteley Index < 3). One subject had to withdraw prior to starting the trial due to medically verified acute physical illness. Results are reported on the 10 subjects (five females and five males) with a mean age of 35.6 (range = 25–59) who completed the study (see Table 1 for baseline characteristics). One subject completed the treatment, including the pre and post-measures, but was lost to follow-up at 3 months. This was a highly educated group with the mean number of years of education = 16 years (range 12(20). All subjects met full DSM-IV-TR criteria for hypochondriasis. Six subjects also met criteria for panic disorder, 2 for major depressive disorder, and 1 for OCD. Participants had a high degree of hypochondriacal symptoms as measured by the Whiteley Index (e.g., Barsky & Ahern, 2004), and a moderate–high degree of somatization as measured by the PHQ-15, with only one subject scoring in the low range (5–10) (Kroenke et al., 2002). Mean score on the SSAS was similar to other hypochondriacal samples reported in the literature (Barsky et al., 1990). The mean TAS for the group was in the non-alexithymic range, but the individual scores indicated that 3 subjects met the TAS criteria for alexithymia (scores greater than 60; Bagby et al., 1994). Baseline mindfulness, as measured by the FFMQ, was substantially lower than a normative, similarly educated, community sample (Baer et al., 2008). 3.2. Treatment outcomes
2.3.9. Five Facet Mindfulness Questionnaire (FFMQ) To assess changes in mindful awareness, one of the putative effects of a mindfulness-based intervention, the 39-item FFMQ was used. It has demonstrated construct validity in meditating and nonmeditating populations (Baer et al., 2008). The scale measures five factors of mindfulness: observing, describing, nonreactivity to experience, nonjudgment of experience, and acting with awareness. An aggregate mindfulness score is presented here, as it is beyond the scope of this pilot study and its small sample to investigate the role of putative factors of mindfulness. 2.3.10. World Health Organization Quality of Life-Bref (WHOQOL-BREF) Quality of life and health was assessed with the WHOQoLBref (WHOQOL Group, 1998). This self-report measure consists of 26 items, assesses 5 domains of quality of life, and has adequate test–retest reliability and discriminate validity. The most pertinent scores of overall quality of life and health satisfaction are presented. Each item was Likert scored from 1 to 5, and participants’ scores are shown as the mean of these 26 ratings, producing a score of 1–5. 2.4. Statistical methods Means and standard deviations were computed for each of the measures at pre-intervention, post-intervention, and 3-month follow-up. Due to the small sample size, non-parametric statistics were applied to the data. Wilcoxon Signed Ranks Tests (paired comparisons pre- to post-treatment, and pre- to 3-month follow-up) were conducted for all self-report measures (with the exception of the TAS and SSAS which were measured for demographic purposes). A Pearson’s correlation was conducted between the change
There were significant reductions in hypochondriacal health anxiety symptoms, as measured by the WI, at post-treatment, and at 3-month follow-up (Table 2). All participants (100%) had reduced WI scores at the end of treatment with an average reduction of 27.1%, and at 3 months, with an average reduction of 33.7%. In terms of the clinical significance of the findings, 3 out of 10 (30%) at post-intervention, and 7 out of 9 participants (77.8%) at 3-month follow-up had WI scores below the cut-off for clinically significant hypochondriasis for this study (<3). A similar and consistent pattern was observed in the secondary outcome measures (see Table 2). Subscales of the HAI showed significant reductions in illness attitude and reassurance seeking, but not avoidance behavior, at post-treatment and 3 months. There also were significant reductions in hypochondriacal thought frequency and believability, as measured by the HCQ, at post-treatment and at 3-month follow-up. Somatic symptom severity also significantly decreased at post-treatment and 3-month follow-up. Depression scores, as measured by the BDI, were also significantly reduced at post and 3 months, but reductions in general anxiety scores, as measured by the BAI, were not significant. Improvement in quality of life and health satisfaction, as measured by the WHOQOL, was not statistically significant at post-intervention, but was significant by 3 months, with an improvement of 18% (p < .05), and 51% (p < .05), respectively (see Table 2). Mindfulness was significantly increased after the 8-week intervention (see Table 2). Improvement in hypochrondriacal symptoms, as measured by the WI, was positively correlated with improvement in mindfulness, as measured by the FFMQ (r = 0.702, p < .05). This is considered to be a large correlation (Cohen, 1988).
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Table 1 Baseline demographics. Percentage (n) Gender Male Female
50 (5) 50 (5)
Relationship/living status Alone/single With SO/spouse
40 (4) 60 (6)
Comorbid diagnoses PD MDD OCD
60 (6) 20 (2) 10 (1)
Mean
Age (years) Education (years) Hypochondriacal symptom duration (years) Whiteley Index [1–5] PHQ-15 [1–30] SSAS [1–5] TAS [20–100] FFMQ [1–5]
Range
35.6 16 15.6 4.09 14 3.38 55 2.83
S.D.
25–59 12–20 3–27 2.71–4.93 6–18 2.90–3.80 42–71 2.38–3.43
9.79 2.83 8.45 0.57 3.62 0.29 9.92 0.33
Note: SO: significant other; PD: panic disorder; MDD: major depressive disorder; OCD: obsessive-compulsive disorder; PHQ-15, Patient Health Questionnaire-15; SSAS, Somatosensory Amplification Scale; TAS, Toronto Alexithymia Scale; FFMQ, Five Factor Mindfulness Questionnaire. Numbers in square brackets in the first column indicate the potential score range for each scale. Higher scores on Whiteley Index and TAS indicate greater psychological distress/symptomatoloy. Higher scores on the PHQ-15 and SSAS indicate greater somatic distress/symptomatology. Higher scores on the FFMQ indicate greater mindful awareness.
Table 2 Summary of outcome measure scores at pre-intervention, post-intervention, and 3-month follow-up, and change in scores from pre- to post-intervention and from pre- to 3-month follow-up. Measure
Whiteley Index [1–5] PHQ-15 [0–30] HAI [0–3] Illness attitude [0–3] Avoidance behavior [0–8] Reassurance seeking [0–8] HCQ [1–5] Believability [0–100] BAI [0–63] BDI-II [0–63] FFMQ [1–5] WHOQOL [1–5] Health sat [1–5]
Baseline (T1)
Post-intervention (T2)
Mean
S.D.
Mean
S.D.
4.26 14 2.07 1.65 2.68 4.20 2.69 34.44 18.6 14.8 2.84 3.5 2.4
0.57 3.62 0.28 0.69 2.22 1.34 0.48 17.9 9.80 8.18 0.33 0.97 0.52
3.02 10.2 1.51 0.90 1.85 2.95 2.13 22.11 14.8 8.8 3.12 4.1 3.2
0.53 3.93 0.26 0.64 1.44 1.23 0.53 16.20 9.68 8.13 0.42 0.88 0.92
Z-score T1 − T2
−2.80** −2.71** −2.81** −2.84** −0.36 ns −2.29* −2.60** −2.55* −1.25 ns −2.40* 2.19* 1.73 ns 1.95 ns
% change T1 − T2
−27% −27 −27 −45 −31 −30 −21 −36 −20 −40 10 17 33
3 months (T3)
Mean
S.D.
2.71 8.33 1.37 1.06 1.73 2.93 1.89 20.83 10 7.44 3.18 4.12 3.62
0.69 3.46 0.41 0.79 1.47 1.20 0.48 17.82 6.48 8.9 0.44 0.83 0.74
Z-score T1 − T3
−2.67** −2.55** −2.67** −2.21** −0.42ns −2.55* −2.55* −2.66** −1.54ns −2.52* 2.67** 2.12* 2.43*
% change T1 − T3
−34% −40 −34 −36 −35 −30 −30 −40 −46 −50 12 18 51
Note: PHQ-15, Patient Health Questionnaire-15; HAI, Health Anxiety Inventory; HCQ, Health Cognitions Questionnaire; SSAS, Somatosensory Amplification Scale; TAS, Toronto Alexithymia Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; FFMQ, Five Factor Mindfulness Questionnaire; WHOQOL, WHO Quality of Life Questionnaire. Higher scores on Whiteley, HAI, HCQ, TAS, BAI, BDI-II indicate greater psychological distress. Higher scores on the PHQ-15 indicate greater somatic distress. Higher scores on the FFMQ indicate increased mindful awareness. Numbers in square brackets in the first column indicate the potential score range for each scale. * p < .05. ** p < .01.
4. Discussion This small, uncontrolled pilot study of MBCT for hypochondriasis, or severe health anxiety, demonstrated a significant decrease in hypochondriacal symptoms following an 8-week group mindfulness intervention, and the reductions were sustained at 3-month follow-up. Moreover, improvement on the primary outcome measure was replicated in the related secondary outcome measures. These included improvements in specific components of the disorder including the frequency and believability of hypochondriacal thoughts, and characteristic reassurance-seeking behaviors. Contrary to a prior study of CBT for hypochondriasis (Barsky & Ahern, 2004), the participants in this trial also demonstrated improvements in somatic symptoms. MBCT appears to be a feasible and acceptable treatment for patients with hypochondriasis given the absence of drop-outs and that all participants gave high subjective ratings of satisfaction.
The important, and potentially mediating role of mindfulness in this treatment is supported by the finding that an increase in mindfulness was highly correlated with improvement in hypochondriasis. This, along with the decline in the frequency and believability of hypochondriacal thoughts, suggests that participants learned the essential skill of being able to de-center from highly charged health-related thoughts and fears, thereby avoiding a ruminative cycle, and preventing engagement in fear-driven, obsessive behaviors, such as reassurance seeking. Limitations of the present study include its small sample size and the absence of a control group. As such, it is possible that the observed improvements resulted from the natural history of the disorder or from the non-specific treatment effects such as support, attention, positive expectations and encouragement. However, given the pre-treatment severity and chronicity of the symptoms in this group, the former explanation seems unlikely. Moreover, the improvements in mindfulness argue for a possible
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specific effect of the intervention. However, future research with a larger sample is necessary to examine potential mediators of effect. Another potential limitation is that the participants did not have isolated diagnoses of hypochondriasis, and carried comorbidities such as panic disorder, and major depressive disorder. However, this sample may be more representative of the broader population of patients with hypochondriasis, as it has been shown that comorbidity with other axis I disorders, especially with mood and anxiety disorders, is as high as 88% (Barsky, Wyshak, & Klerman, 1992). Notably, the current sample was also uniformly employed, and fairly highly educated, which may not be generalizable to the larger population of patients with severe health anxiety. Future research should seek to replicate these findings in randomized, controlled trials conducted with larger and more diverse samples, and with longer follow-up. The group format used in this study may prove particularly advantageous given the elevated healthcare costs and burdens associated with this condition in primary care settings. Therefore, future work should also assess the cost-benefit value of this intervention, and the feasibility of dissemination into primary care. Acknowledgements This research was supported by the Dupont-Warren and Livingston Fellowship grants of the Harvard Medical School, as well as by the Cambridge Health Alliance, Department of Psychiatry. The authors wish to thank Christopher Germer, PhD and Robert Joseph, MD for their supervision and support of this study. References Abramowitz, J. S., & Braddock, A. E. (2008). Psychological treatment of health anxiety & hypochondriasis: a biopsychosocial approach. Cambridge, MA: Hogrefe & Huber Publishing. Abramowitz, J. S., Schwartz, S. A., & Whiteside, S. P. (2001). A contemporary conceptual model of hypochondriasis. Mayo Clinic Proceedings, 77, 1323–1330. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text-revision. Washington, DC: American Psychiatric Association. Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., et al. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 15, 329–342. Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32. Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. Journal of the American Medical Association, 291, 1464–1470. Barsky, A. J., & Wyshak, G. (1990). Hypochondriasis and somatosensory amplification. British Journal of Psychiatry, 157, 404–409. Barsky, A. J., Wyshak, G., & Klerman, G. L. (1992). Psychiatric comorbidity in DSM-III-R hypochondriasis. Archives of General Psychiatry, 49, 101–108. Barsky, A. J., Wyshak, G., & Klerman, G. L. (1990). The Somatosensory Amplification Scale and its relationship to hypochondriasis. Journal of Psychiatric Research, 24, 323–334. Beck, A. T., & Steer, R. A. (1990). Beck anxiety inventory manual. San Antonio, TX: The Psychological Corporation.
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Beck, A. T., Steer, R. A., & Garbin, M. G. (1998). Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review, 8, 77–100. Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al. (1998). Two psychological treatments for hypochondriasis. A randomised controlled trial. The British Journal of Psychiatry, 173, 218–225. Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hilldale, NJ: Lawrence Erlbaum Associates, Inc. Publishers. Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22, 716–721. Faravelli, C., Salvatori, S., Galassi, F., Aiazzi, L., Drei, C., & Cabras, P. (1997). Epidemiology of somatoform disorders: a community survey in Florence. Social Psychiatry & Psychiatric Epidemiology, 32, 24–29. Greeven, A., van Balkom, A. J. L. M., Visser, S., Merkelbach, J. W., van Rood, Y. R., van Dyck, R., et al. (2007). Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. American Journal of Psychiatry, 164, 91–99. Jain, S., Shapiro, S. L., Swanick, S., Roesch, S. C., Mills, P. J., Bell, I., et al. (2007). A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Annals of Behavioral Medicine, 33, 11–21. Jha, A. P., Krompinger, J., & Baime, M. J. (2007). Mindfulness training modifies subsystems of attention. Cognitive, Affective, & Behavioral Neuroscience, 7, 109–119. Kabat-Zinn, J. (1990). Full catastrophe living. New York: Delta Publishing. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64, 258–266. Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., Treadway, M. T., et al. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport, 16, 1893–1897. Marcus, D. K., Hughes, K. T., & Arnau, R. C. (2008). Health anxiety, rumination, and negative affect: a mediational analysis. Journal of Psychosomatic Research, 64, 495–501. Mykletun, A., Heradstveit, O., Eriksen, K., Glozier, N., Øverland, S., Maeland, J. G., et al. (2009). Health anxiety and disability pension award: the HUSK Study. Psychosomatic Medicine, 71, 353–360. olde Hartman, T. C., Borghuis, M. S., Lucassen, P. L., van de Laar, F. A., Speckens, A. E., & van Weel, C. (2009). Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. Journal of Psychosomatic Research, 66, 363–377. Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal of Psychiatry, 113, 89–93. Pilowsky, I. (1978). A general classification of abnormal illness behaviours. British Journal of Medical Psychology, 51, 131–137. Rassin, E., Muris, P., Franken, I., & van Straten, M. (2008). The feature-positive effect and hypochondriacal concerns. Behaviour Research and Therapy, 46, 263– 269. Salkovskis, P. M., Rimes, K. A., Warwick, H. M. C., & Clark, D. M. (2002). The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32, 843–853. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York: Gilford Press. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22–33. Taylor, S., & Asmundson, G. J. G. (2004). Treating health anxiety: a cognitive-behavioral approach. New York: Guilford Press. Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulnessbased cognitive therapy. Journal of Consulting and Clinical Psychology, 6, 615– 623. WHOQOL Group. (1998). Development of the World Health Organization WHOQOLBREF quality of life assessment. Psychological Medicine, 28, 551–558.
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
Mindfulness-based cognitive therapy for hypochondriasis, or severe health anxiety: A pilot study David A. Lovas a,b,c,∗ , Arthur J. Barsky a,1 a b c
Department of Psychiatry, Harvard Medical School, Boston, MA, United States Cambridge Health Alliance, Cambridge, MA, United States Massachusetts General Hospital, Boston, MA, United States
a r t i c l e
i n f o
Article history: Received 24 November 2009 Received in revised form 18 June 2010 Accepted 19 June 2010 Keywords: Hypochondriasis Health Anxiety Cognitive therapy Mindfulness
a b s t r a c t In spite of the existence of evidence-based treatments for hypochondriasis, or severe health anxiety, recovery rates are low and morbidity is high. Therefore, more treatment options are needed for this prevalent condition. Mindfulness-based cognitive therapy (MBCT) interventions have been gaining research and clinical attention for the treatment of mood, and more recently anxiety disorders. A small, uncontrolled pilot study of an 8-week group MBCT intervention for hypochondriasis was conducted. Ten subjects (five females and five males) with a mean age of 35.6 (range = 25–59) recruited from an academic community health network met criteria and completed the study. There were significant improvements in measures of health anxiety, disease-related thoughts, somatic symptoms, and mindfulness at the end of treatment, and these benefits were sustained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no drop-outs or adverse events. These findings provide the basis for a larger, more rigorous, controlled trial of this promising treatment approach. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Researchers have been increasingly conceptualizing health anxiety as existing on a spectrum (Abramowitz & Braddock, 2008; Taylor & Asmundson, 2004). On the mild end, it is an adaptive signal that helps to promote survival-oriented behaviors. However, in the case of severe health anxiety, or hypochondriasis, as it is defined in the DSM-IV-TR (APA, 2000), benign bodily sensations trigger anxiety that reaches a dysfunctional level in which fears and beliefs persist in spite of medical reassurance to the contrary. This can in turn lead to maladaptive checking and reassuranceseeking behaviors, which, at their worst, can be associated with iatrogenic harm. Hypochondriasis affects approximately 5% of primary care patients (Barsky, Wyshak, & Klerman, 1990; Faravelli et al., 1997), and is associated with significant impairment (Mykletun et al., 2009). Although there are several large randomized control trials (RCT) demonstrating the efficacy of cognitive behavioral therapy (CBT) and selective-serotonin reuptake inhibitor antidepressants (Barsky & Ahern, 2004; Clark et al., 1998; Greeven et al., 2007), a recent systematic review revealed that the recovery rate
∗ Corresponding author. Present address: Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, YAW 6A, Boston, MA 02114, United States. Tel.: +1 617 724 6300; fax: +1 617 726 9136. E-mail address: [email protected] (D.A. Lovas). 1 Present address: Massachusetts General Hospital, United States. 0887-6185/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2010.06.019
from hypochondriasis is only 30–50% (olde Hartman et al., 2009), and drop out rates from treatment are as high as 25% (Greeven et al., 2007). Thus, more treatment options are needed. The majority of CBT interventions for hypochondriasis are based on an empirically grounded cognitive-perceptual model of the disorder (e.g., Abramowitz, Schwartz, & Whiteside, 2001; Taylor & Asmundson, 2004). This model postulates that patients with significant health anxiety hold dysfunctional beliefs about health and misinterpret innocuous bodily sensations as dangerous. This leads to a cascade of anxiety and heightened physiological arousal which creates more symptoms and an intensification of pre-existing ones. Thus, prior CBT interventions have sought to decrease this arousal through relaxation training, and to change dysfunctional beliefs through cognitive restructuring. However, there is evidence that severe health anxiety is associated not only with abnormal beliefs, but also with dysfunctional cognitive processing, including a propensity for attentional biases (Rassin, Muris, Franken, & van Straten, 2008), and for rumination (Marcus, Hughes, & Arnau, 2008). Mindfulness-based cognitive therapy (MBCT) interventions have been gaining research and clinical attention for the treatment of mood (Segal, Williams, & Teasdale, 2002; Teasdale et al., 2000), and more recently, anxiety disorders (Evans et al., 2008). These interventions differ from traditional CBT in that they do not attempt to change dysfunctional beliefs, but rather to change the thought process. Studies have shown that mindfulness-based interventions are associated with decreased ruminative thoughts (Jain
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et al., 2007). Additionally, emerging evidence suggests that mindfulness meditation, the central technique in mindfulness-based interventions, is associated with adaptive changes in attention (Jha, Krompinger, & Baime, 2007), and in areas of the brain associated with interoception (Lazar et al., 2005). Thus, it was hypothesized that MBCT might be a beneficial intervention for patients with hypochondriasis, or severe health anxiety. Specifically, it was hypothesized that teaching MBCT in this population would result in decreased overall hypochondriacal symptoms, with specific reductions in the frequency and believability of health-related ruminations. It was also hypothesized that there would be improvements in quality of life after the intervention. Lastly, it was hypothesized that improvements in the primary outcome measure of health anxiety would be correlated with improvements in mindfulness. 2. Method 2.1. Participants Participants were recruited from an academic community hospital setting via posted notices around the hospital and primary care clinics, and via email announcements to the primary care medicine and psychiatry faculty. A senior psychiatry resident screened interested subjects for inclusion and exclusion criteria using the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). Inclusion criteria were (a) over 18 years of age, (b) English speaking, (c) medical stability, (d) meeting criteria for significant health anxiety, as determined by a mean per item score on the Whiteley Index of greater than 3, and a diagnosis of “hypochondriasis” based on DSM-IV-TR criteria. Consistent with prior MBCT studies of anxiety (Evans et al., 2008), and prior CBT studies of hypochondriasis (e.g., Barsky & Ahern, 2004), the following were set as exclusion criteria: comorbid, current, moderate–severe major depression (as assessed by BDI score); current psychoactive substance abuse or dependence; psychosis; pregnancy; and ongoing, symptom-contingent, disability determinations, workers’ compensation proceedings, or litigation. Suicide risk was assessed by the MINI suicide module, and individuals scoring in the moderate and high range were also excluded. 2.2. Procedure At baseline, end of treatment, and at 3-month follow-up, participants completed self-report measures of health anxiety, disease-related thoughts, somatic symptoms, somatosensory amplification, general anxiety and mood, and quality of life. A measure of mindfulness, the predicted mediator of effect, was also collected. MBCT was administered in a group format with eight 2-h sessions at weekly intervals. The group was led by a senior psychiatry resident who had completed training in MBCT and had several years of clinical experience. The intervention was educational in focus, and was based on the pre-existing models of Mindfulness-Based Stress Reduction (MBSR) and MBCT, by Kabat-Zinn (1990) and Segal et al. (2002), respectively. Participants were taught mindfulness meditation, including body scan, mindful breathing, and mindful movement practices. While these prior models emphasized the theoretical mechanisms underlying stress and depression-relapse, respectively, the current treatment focused on the putative cognitive-perceptual mechanisms involved in the production and maintenance of hypochondriacal symptoms. Each session followed an agenda and highlighted a different element of this model, along with specific formal and informal mindfulness practices. Many experientially learned concepts were generic to all mindfulness interventions,
such as the ability to de-center from one’s thoughts, and realize that “thoughts are just thoughts—not facts”. Other concepts were more specific to hypochondriasis, such as noticing the relationship between the quality of one’s attention – worried attention versus mindful attention – and amplification of symptoms. Most learning was experiential via the mindfulness practices, and the group process facilitated shared experience, discussion, and trouble-shooting regarding the techniques. Participants were provided guided meditation CDs and were asked to practice the formal meditations at least 30 min every day and to record their practice. 2.3. Measures 2.3.1. Whiteley Index (WI) The primary outcome measure was the WI due to its wide use in assessing health anxiety and hypochondriacal attitudes and beliefs. Reliability, validity, and sensitivity to change of this 14-item selfreport questionnaire is well established (Pilowsky, 1967, 1978). Each item was Likert scored from 1 to 5, and participants’ scores are shown as the mean of these 14 ratings, producing a score of 1–5. The Whiteley Index does not have clearly defined clinical cutoffs, but in unpublished data of one of the authors (AJB), it was found that 120 subjects meeting DSM-III-R criteria for hypochondriasis had a mean WI score of 3.3, with a S.D. of 0.7. Therefore, a cut-off score of 3 was chosen as an even number that is within 1 S.D. of the mean, with the aim of providing a sufficiently stringent cut-off to detect a clinically significant population, but not be overly exclusive to limit the sample size. 2.3.2. Health Anxiety Inventory (HAI) The HAI is a 14-item, self-report questionnaire measuring health anxiety that is minimally influenced by presence of major medical illness and has good validity, internal consistency, and reliability (Salkovskis, Rimes, Warwick, & Clark, 2002). Each item was Likert scored from 0 to 3, and participants’ scores are shown as the mean of these 14 ratings, producing a score of 0–3. The additional illness attitude, avoidance, and reassurance-seeking scales within this questionnaire were scored separately, and were not added to the total HAI score, as is customary for this scale. The illness attitude section is composed of 4 items, which were each Likert scored from 0 to 3, and participants’ scores are shown as the mean of these 4 ratings, producing a score of 0–3. The avoidance section is composed of 10 items, which were each Likert scored from 0 to 8, and participants’ scores are shown as the mean of these 10 ratings, producing a score of 0–8. The reassurance-seeking section is composed of 10 items, which were each Likert scored from 0 to 8, and participants’ scores are shown as the mean of these 10 ratings, producing a score of 0–8. The authors are not aware of clinical cut-offs for the HAI. 2.3.3. Hypochondriacal Cognitions Questionnaire (HCQ) Frequency and believability of hypochondriacal thoughts were assessed with the HCQ. It is a self-report questionnaire that asks respondents to rate the frequency of 18 disease-related thoughts on a Likert scale of 1–5. Participants’ scores are shown as the mean of these 18 ratings, producing a score of 1–5. It also asks respondents to rate the believability of these thoughts as a percentage from 0 to 100%, and the scores are shown as the mean of these 18 rating, producing a score of 0–100. The HCQ has been used previously in a large RCT of CBT for hypochondriasis (Barsky & Ahern, 2004). There are no clinical cut-offs for the HCQ. 2.3.4. Patient Health Questionnaire-15 (PHQ-15) PHQ-15 (Kroenke, Spitzer, & Williams, 2002) is a 15-item selfreport measure of the subjective severity of somatic symptoms, with established validity and reliability in somatoform disorder and primary care populations. It has been widely used as an index
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of somatization. Scoring denotes levels of low (6–10), medium (11–15), or high (16–30) somatic symptom severity.
in the primary outcome measure of hypochondriasis, and the change in mindfulness.
2.3.5. Somatosensory Amplification Scale (SSAS) The tendency to amplify benign bodily sensation and experience it as noxious, unpleasant, and alarming was assessed with the 10item SSAS. It has good reliability and validity (Barsky & Wyshak, 1990; Barsky et al., 1990). Each item was Likert scored from 1 to 5, and participants’ scores are shown as the mean of these 10 ratings, producing a score of 1–5. There are no clinical cut-offs for the SSAS.
3. Results
2.3.6. Toronto Alexithymia Scale (TAS) The TAS (Bagby, Parker, & Taylor, 1994) is a widely used 20-item self-report measure of alexithymia—the relative inability to identify and describe emotions. Alexithymia has been found to be an important predisposing personality variable for somatoform disorders, and the TAS has established validity and reliability in these populations. The TAS has established cut-offs for scoring, denoting non-alexithymia (51 or less), possible alexithymia (52–60), and alexithymia (61 and higher). 2.3.7. Beck Anxiety Inventory (BAI) The BAI (Beck & Steer, 1990) is a widely used 21-item selfreport measure of anxiety with high reliability and validity. Scoring denotes levels of minimal (0–7), mild (8–15), moderate (16–25), and severe (25–63) anxiety. 2.3.8. Beck Depression Inventory-II (BDI-II) The BDI-II (Beck, Steer, & Garbin, 1998) is a widely used 21-item self-report measure of depression with well-established psychometric properties and with high reliability and validity. Scoring denotes levels of minimal (0–13), mild (14–19), moderate (20(28), and severe (29–63) depression.
3.1. Demographic characteristics Of the 18 subjects who were screened for the study, 10 met inclusion criteria and participated in the study. Seven subjects were excluded due to subthreshold scores on the primary outcome measure at screening (Whiteley Index < 3). One subject had to withdraw prior to starting the trial due to medically verified acute physical illness. Results are reported on the 10 subjects (five females and five males) with a mean age of 35.6 (range = 25–59) who completed the study (see Table 1 for baseline characteristics). One subject completed the treatment, including the pre and post-measures, but was lost to follow-up at 3 months. This was a highly educated group with the mean number of years of education = 16 years (range 12(20). All subjects met full DSM-IV-TR criteria for hypochondriasis. Six subjects also met criteria for panic disorder, 2 for major depressive disorder, and 1 for OCD. Participants had a high degree of hypochondriacal symptoms as measured by the Whiteley Index (e.g., Barsky & Ahern, 2004), and a moderate–high degree of somatization as measured by the PHQ-15, with only one subject scoring in the low range (5–10) (Kroenke et al., 2002). Mean score on the SSAS was similar to other hypochondriacal samples reported in the literature (Barsky et al., 1990). The mean TAS for the group was in the non-alexithymic range, but the individual scores indicated that 3 subjects met the TAS criteria for alexithymia (scores greater than 60; Bagby et al., 1994). Baseline mindfulness, as measured by the FFMQ, was substantially lower than a normative, similarly educated, community sample (Baer et al., 2008). 3.2. Treatment outcomes
2.3.9. Five Facet Mindfulness Questionnaire (FFMQ) To assess changes in mindful awareness, one of the putative effects of a mindfulness-based intervention, the 39-item FFMQ was used. It has demonstrated construct validity in meditating and nonmeditating populations (Baer et al., 2008). The scale measures five factors of mindfulness: observing, describing, nonreactivity to experience, nonjudgment of experience, and acting with awareness. An aggregate mindfulness score is presented here, as it is beyond the scope of this pilot study and its small sample to investigate the role of putative factors of mindfulness. 2.3.10. World Health Organization Quality of Life-Bref (WHOQOL-BREF) Quality of life and health was assessed with the WHOQoLBref (WHOQOL Group, 1998). This self-report measure consists of 26 items, assesses 5 domains of quality of life, and has adequate test–retest reliability and discriminate validity. The most pertinent scores of overall quality of life and health satisfaction are presented. Each item was Likert scored from 1 to 5, and participants’ scores are shown as the mean of these 26 ratings, producing a score of 1–5. 2.4. Statistical methods Means and standard deviations were computed for each of the measures at pre-intervention, post-intervention, and 3-month follow-up. Due to the small sample size, non-parametric statistics were applied to the data. Wilcoxon Signed Ranks Tests (paired comparisons pre- to post-treatment, and pre- to 3-month follow-up) were conducted for all self-report measures (with the exception of the TAS and SSAS which were measured for demographic purposes). A Pearson’s correlation was conducted between the change
There were significant reductions in hypochondriacal health anxiety symptoms, as measured by the WI, at post-treatment, and at 3-month follow-up (Table 2). All participants (100%) had reduced WI scores at the end of treatment with an average reduction of 27.1%, and at 3 months, with an average reduction of 33.7%. In terms of the clinical significance of the findings, 3 out of 10 (30%) at post-intervention, and 7 out of 9 participants (77.8%) at 3-month follow-up had WI scores below the cut-off for clinically significant hypochondriasis for this study (<3). A similar and consistent pattern was observed in the secondary outcome measures (see Table 2). Subscales of the HAI showed significant reductions in illness attitude and reassurance seeking, but not avoidance behavior, at post-treatment and 3 months. There also were significant reductions in hypochondriacal thought frequency and believability, as measured by the HCQ, at post-treatment and at 3-month follow-up. Somatic symptom severity also significantly decreased at post-treatment and 3-month follow-up. Depression scores, as measured by the BDI, were also significantly reduced at post and 3 months, but reductions in general anxiety scores, as measured by the BAI, were not significant. Improvement in quality of life and health satisfaction, as measured by the WHOQOL, was not statistically significant at post-intervention, but was significant by 3 months, with an improvement of 18% (p < .05), and 51% (p < .05), respectively (see Table 2). Mindfulness was significantly increased after the 8-week intervention (see Table 2). Improvement in hypochrondriacal symptoms, as measured by the WI, was positively correlated with improvement in mindfulness, as measured by the FFMQ (r = 0.702, p < .05). This is considered to be a large correlation (Cohen, 1988).
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Table 1 Baseline demographics. Percentage (n) Gender Male Female
50 (5) 50 (5)
Relationship/living status Alone/single With SO/spouse
40 (4) 60 (6)
Comorbid diagnoses PD MDD OCD
60 (6) 20 (2) 10 (1)
Mean
Age (years) Education (years) Hypochondriacal symptom duration (years) Whiteley Index [1–5] PHQ-15 [1–30] SSAS [1–5] TAS [20–100] FFMQ [1–5]
Range
35.6 16 15.6 4.09 14 3.38 55 2.83
S.D.
25–59 12–20 3–27 2.71–4.93 6–18 2.90–3.80 42–71 2.38–3.43
9.79 2.83 8.45 0.57 3.62 0.29 9.92 0.33
Note: SO: significant other; PD: panic disorder; MDD: major depressive disorder; OCD: obsessive-compulsive disorder; PHQ-15, Patient Health Questionnaire-15; SSAS, Somatosensory Amplification Scale; TAS, Toronto Alexithymia Scale; FFMQ, Five Factor Mindfulness Questionnaire. Numbers in square brackets in the first column indicate the potential score range for each scale. Higher scores on Whiteley Index and TAS indicate greater psychological distress/symptomatoloy. Higher scores on the PHQ-15 and SSAS indicate greater somatic distress/symptomatology. Higher scores on the FFMQ indicate greater mindful awareness.
Table 2 Summary of outcome measure scores at pre-intervention, post-intervention, and 3-month follow-up, and change in scores from pre- to post-intervention and from pre- to 3-month follow-up. Measure
Whiteley Index [1–5] PHQ-15 [0–30] HAI [0–3] Illness attitude [0–3] Avoidance behavior [0–8] Reassurance seeking [0–8] HCQ [1–5] Believability [0–100] BAI [0–63] BDI-II [0–63] FFMQ [1–5] WHOQOL [1–5] Health sat [1–5]
Baseline (T1)
Post-intervention (T2)
Mean
S.D.
Mean
S.D.
4.26 14 2.07 1.65 2.68 4.20 2.69 34.44 18.6 14.8 2.84 3.5 2.4
0.57 3.62 0.28 0.69 2.22 1.34 0.48 17.9 9.80 8.18 0.33 0.97 0.52
3.02 10.2 1.51 0.90 1.85 2.95 2.13 22.11 14.8 8.8 3.12 4.1 3.2
0.53 3.93 0.26 0.64 1.44 1.23 0.53 16.20 9.68 8.13 0.42 0.88 0.92
Z-score T1 − T2
−2.80** −2.71** −2.81** −2.84** −0.36 ns −2.29* −2.60** −2.55* −1.25 ns −2.40* 2.19* 1.73 ns 1.95 ns
% change T1 − T2
−27% −27 −27 −45 −31 −30 −21 −36 −20 −40 10 17 33
3 months (T3)
Mean
S.D.
2.71 8.33 1.37 1.06 1.73 2.93 1.89 20.83 10 7.44 3.18 4.12 3.62
0.69 3.46 0.41 0.79 1.47 1.20 0.48 17.82 6.48 8.9 0.44 0.83 0.74
Z-score T1 − T3
−2.67** −2.55** −2.67** −2.21** −0.42ns −2.55* −2.55* −2.66** −1.54ns −2.52* 2.67** 2.12* 2.43*
% change T1 − T3
−34% −40 −34 −36 −35 −30 −30 −40 −46 −50 12 18 51
Note: PHQ-15, Patient Health Questionnaire-15; HAI, Health Anxiety Inventory; HCQ, Health Cognitions Questionnaire; SSAS, Somatosensory Amplification Scale; TAS, Toronto Alexithymia Scale; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; FFMQ, Five Factor Mindfulness Questionnaire; WHOQOL, WHO Quality of Life Questionnaire. Higher scores on Whiteley, HAI, HCQ, TAS, BAI, BDI-II indicate greater psychological distress. Higher scores on the PHQ-15 indicate greater somatic distress. Higher scores on the FFMQ indicate increased mindful awareness. Numbers in square brackets in the first column indicate the potential score range for each scale. * p < .05. ** p < .01.
4. Discussion This small, uncontrolled pilot study of MBCT for hypochondriasis, or severe health anxiety, demonstrated a significant decrease in hypochondriacal symptoms following an 8-week group mindfulness intervention, and the reductions were sustained at 3-month follow-up. Moreover, improvement on the primary outcome measure was replicated in the related secondary outcome measures. These included improvements in specific components of the disorder including the frequency and believability of hypochondriacal thoughts, and characteristic reassurance-seeking behaviors. Contrary to a prior study of CBT for hypochondriasis (Barsky & Ahern, 2004), the participants in this trial also demonstrated improvements in somatic symptoms. MBCT appears to be a feasible and acceptable treatment for patients with hypochondriasis given the absence of drop-outs and that all participants gave high subjective ratings of satisfaction.
The important, and potentially mediating role of mindfulness in this treatment is supported by the finding that an increase in mindfulness was highly correlated with improvement in hypochondriasis. This, along with the decline in the frequency and believability of hypochondriacal thoughts, suggests that participants learned the essential skill of being able to de-center from highly charged health-related thoughts and fears, thereby avoiding a ruminative cycle, and preventing engagement in fear-driven, obsessive behaviors, such as reassurance seeking. Limitations of the present study include its small sample size and the absence of a control group. As such, it is possible that the observed improvements resulted from the natural history of the disorder or from the non-specific treatment effects such as support, attention, positive expectations and encouragement. However, given the pre-treatment severity and chronicity of the symptoms in this group, the former explanation seems unlikely. Moreover, the improvements in mindfulness argue for a possible
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specific effect of the intervention. However, future research with a larger sample is necessary to examine potential mediators of effect. Another potential limitation is that the participants did not have isolated diagnoses of hypochondriasis, and carried comorbidities such as panic disorder, and major depressive disorder. However, this sample may be more representative of the broader population of patients with hypochondriasis, as it has been shown that comorbidity with other axis I disorders, especially with mood and anxiety disorders, is as high as 88% (Barsky, Wyshak, & Klerman, 1992). Notably, the current sample was also uniformly employed, and fairly highly educated, which may not be generalizable to the larger population of patients with severe health anxiety. Future research should seek to replicate these findings in randomized, controlled trials conducted with larger and more diverse samples, and with longer follow-up. The group format used in this study may prove particularly advantageous given the elevated healthcare costs and burdens associated with this condition in primary care settings. Therefore, future work should also assess the cost-benefit value of this intervention, and the feasibility of dissemination into primary care. Acknowledgements This research was supported by the Dupont-Warren and Livingston Fellowship grants of the Harvard Medical School, as well as by the Cambridge Health Alliance, Department of Psychiatry. The authors wish to thank Christopher Germer, PhD and Robert Joseph, MD for their supervision and support of this study. References Abramowitz, J. S., & Braddock, A. E. (2008). Psychological treatment of health anxiety & hypochondriasis: a biopsychosocial approach. Cambridge, MA: Hogrefe & Huber Publishing. Abramowitz, J. S., Schwartz, S. A., & Whiteside, S. P. (2001). A contemporary conceptual model of hypochondriasis. Mayo Clinic Proceedings, 77, 1323–1330. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text-revision. Washington, DC: American Psychiatric Association. Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., et al. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 15, 329–342. Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32. Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. Journal of the American Medical Association, 291, 1464–1470. Barsky, A. J., & Wyshak, G. (1990). Hypochondriasis and somatosensory amplification. British Journal of Psychiatry, 157, 404–409. Barsky, A. J., Wyshak, G., & Klerman, G. L. (1992). Psychiatric comorbidity in DSM-III-R hypochondriasis. Archives of General Psychiatry, 49, 101–108. Barsky, A. J., Wyshak, G., & Klerman, G. L. (1990). The Somatosensory Amplification Scale and its relationship to hypochondriasis. Journal of Psychiatric Research, 24, 323–334. Beck, A. T., & Steer, R. A. (1990). Beck anxiety inventory manual. San Antonio, TX: The Psychological Corporation.
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