Patient Characteristics and Patient Behavior as Predictors of Outcome in Cognitive Therapy and Exposure Therapy for Hypochondriasis.

OBJECTIVE: Psychotherapy for hypochondriasis has greatly improved over the last decades and cognitive-behavioral treatments are most promising. However, research on predictors of treatment outcome for hypochondriasis is rare. Possible predictors of treatment outcome in cognitive therapy (CT) and exposure therapy (ET) for hypochondriasis were investigated. METHOD: Characteristics and behaviors of 75 patients were considered as possible predictors: sociodemographic variables (sex, age, and cohabitation); psychopathology (pretreatment hypochondriacal symptoms, comorbid mental disorders, and levels of depression, anxiety, and somatic symptoms); and patient in-session interpersonal behavior. RESULTS: Severity of pretreatment hypochondriacal symptoms, comorbid mental disorders, and patient in-session interpersonal behavior were significant predictors in multiple hierarchical regression analyses. Interactions between the predictors and the treatment (CT or ET) were not found. CONCLUSIONS: In-session interpersonal behavior is an important predictor of outcome. Furthermore, there are no specific contraindications to treating hypochondriasis with CT or ET.

Personality Disorders in Hypochondriasis: A Comparison to Panic Disorder and Healthy Controls.

Previous studies found high prevalence rates of personality disorders (PDs) in patients with hypochondriasis; however, assessment was often based only on questionnaires. In the current study, a sample of 68 patients with hypochondriasis was compared to 31 patients with panic disorder and to 94 healthy controls. Participants were investigated with the Structured Clinical Interview for DSM-IV Personality Disorders questionnaire (SCID-II questionnaire) and the SCID-II interview. Based on the cut-off scores of the SCID-II questionnaire, we found a prevalence rate of 45.6% for PD in patients with hypochondriasis. In comparison to healthy controls, patients with hypochondriasis showed characteristics of paranoid, borderline, avoidant, and dependent PDs in the dimensional assessment significantly more often. However, no significant differences were found between the clinical samples. Based on the SCID-II interview, only 2.9% of the patients with hypochondriasis fulfilled the criteria for a PD. These results suggest that PDs are not a specific characteristic of hypochondriasis.

Assessment of patient interpersonal behavior: Development and validation of a rating scale.

OBJECTIVE: Patient in-session interpersonal behavior, as part of the therapeutic alliance, is an important aspect of the psychotherapy process and impacts treatment outcome. In the present study, the development and validation of a rating scale of patient in-session interpersonal behavior is described. METHOD: A 10-item rating scale, the Assessment Form of Patient Interpersonal Behavior (AFPIB), was developed using an inductive procedure. The AFPIB was then validated in a sample of patients with hypochondriasis (N = 30), by having two independent raters assess patients' interpersonal behaviors shown in videotaped psychotherapy sessions (N = 60). RESULTS: The AFPIB demonstrated good reliability and validity. CONCLUSIONS: Thus, the AFPIB seems to be a promising rating scale for the assessment of patient interpersonal behavior shown in psychotherapy sessions.

Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis).

The role of treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) is rarely investigated in psychotherapeutic treatment for health anxiety. This study aimed to investigate the role of the assessment perspective for the evaluation of treatment delivery factors and their relevance for treatment outcome. Therapist adherence, therapist competence, and therapeutic alliance were evaluated by independent raters, therapists, patients, and supervisors in 68 treatments. Patients with severe health anxiety (hypochondriasis) were treated with cognitive therapy or exposure therapy. Treatment outcome was assessed with a standardized interview by independent diagnosticians. A multitrait-multimethod analysis revealed a large effect for the assessment perspective of therapist adherence, therapist competence, and therapeutic alliance. The rater perspective was the most important for the prediction of treatment outcome. Therapeutic alliance and therapist competence accounted for 6% of the variance of treatment outcome while therapist adherence was not associated with treatment outcome. Therapist competence was only indirectly associated with treatment outcome, mediated by therapeutic alliance. Both therapeutic alliance and therapist competence demonstrated to be important treatment delivery factors in psychotherapy for health anxiety. A stronger consideration of those processes during psychotherapy for health anxiety might be able to improve psychotherapy outcome.

Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): A randomized controlled trial.

OBJECTIVE: Cognitive-behavioral therapy has proven to be highly effective in the treatment of hypochondriasis and health anxiety. However, little is known about which therapeutic interventions are most promising. The aim of the present study was to compare the efficacy of cognitive therapy (CT) with exposure therapy (ET). METHOD: Eighty-four patients with a diagnosis of hypochondriasis were randomly allocated to CT, ET, or a waiting list (WL) control group. The primary outcome measure was a standardized interview that evaluated hypochondriacal cognitions as well as behaviors conducted by independent diagnosticians. Several self-report questionnaires were evaluated as secondary outcome measures. Treatment success was evaluated at posttreatment and at 1-year follow-up. RESULTS: Both CT (Hedges's g = 1.01-1.11) and ET (Hedges's g = 1.21-1.24) demonstrated their efficacy in comparison with the WL in the primary outcome measure. Moreover, a significant reduction in depressive symptoms and bodily complaints was found in the secondary outcome measures for both treatments in comparison with the WL, but anxiety symptoms were only significantly reduced by ET. In a direct comparison, no significant differences were found between CT and ET in the primary or the secondary outcome measures. Regarding safety behaviors, we found a significantly larger improvement with ET than with CT in the completer analyses. CONCLUSIONS: The results suggest high efficacy of CT as well as ET in the treatment of hypochondriasis. Cognitive interventions were not a necessary condition for the change of dysfunctional cognitions. These findings are relevant to the conceptualization and psychotherapeutic treatment of hypochondriasis and health anxiety.

Nondisclosure during psychotherapy supervision: validation of the German version of the supervisory questionnaire (SQ).

Nondisclosure is considered to be a central obstacle to effective psychotherapy supervision. The aim of the current study was the validation of the German version of the Supervisory Questionnaire (SQ; Yourman & Farber, 1996), a short measure for the assessment of supervisee nondisclosure. The investigation was based on a sample of 589 supervisees. Confirmatory factor analyses suggested a two-factor model of the SQ which included one factor describing nondisclosure regarding the patient (α=.74) and another describing nondisclosure regarding the supervisor (α=.71). The SQ demonstrated satisfactory convergent and discriminant validity. Additionally assessed supervisee characteristics accounted for 16% of the variance in nondisclosure. These results provide general support for the reliability and validity of the SQ in a large sample of supervisees.

The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: secondary analysis of a randomized trial.

Meta-analyses reveal that homework compliance is associated with a better treatment outcome. However, little is known about the processes that could be responsible for patient compliance with homework. It has been proposed that therapist competence, in particular with respect to reviewing homework, is highly relevant for homework compliance. The present study is a secondary analysis of a randomized controlled trial. Altogether, 54 patients with recurrent depressive disorder (currently in remission) who were treated with maintenance cognitive therapy (MCT), were considered. One videotaped treatment session of each patient was randomly selected and therapist competence (general competence and specific competence in setting and reviewing homework) was assessed by 2 independent raters. Furthermore, both patient and therapist views of the therapeutic alliance were evaluated by questionnaire in this therapy session. Homework compliance (considering quantitative as well as qualitative aspects) in the following session was evaluated by 2 additional raters. These 2 raters were blinded regarding the ratings of the therapeutic competence. In a multilevel path analysis model, a significant association between the therapeutic competence in reviewing homework and homework compliance was detected, while the therapeutic alliance and several patient characteristics were not associated with homework compliance. We found no relationship between homework compliance and treatment outcome. Our results demonstrate that a specific therapeutic competence (i.e., competence in reviewing homework) is associated with patient compliance with homework, and therefore, provides further empirical evidence of the importance of therapist competence in the psychotherapeutic process.

The restrictive concept of good health in patients with hypochondriasis.

The restrictive concept of good health and the misinterpretation of bodily symptoms as a sign of illness are considered in the DSM and in well-established cognitive models as central characteristics of hypochondriasis. However, until now it has not been satisfactorily resolved whether this tendency is unique for hypochondriasis. In the current study a modified card sorting technique was used to investigate the extent to which bodily complaints were seen as compatible with a state of good health. We found that patients with hypochondriasis (n = 45) showed a more restrictive concept of good health than anxiety patients (n = 45) and healthy controls (n = 45). Those differences were only observable when a concrete evaluation of own bodily symptoms was carried out in comparison to a more general evaluation of symptoms. The misinterpretation of bodily symptoms demonstrates to be a highly specific characteristic of hypochondriasis.

Dysfunctional beliefs about symptoms and illness in patients with hypochondriasis.

BACKGROUND: The cognitive model and empirical research underline the importance of dysfunctional beliefs about bodily symptoms and illness in health anxiety and hypochondriasis. However, specificity of such beliefs has not yet been adequately demonstrated for patients with hypochondriasis. OBJECTIVE: This study examined whether dysfunctional beliefs about bodily symptoms and illness are elevated in comparison to patients with anxiety disorders and, therefore, specific for patients with hypochondriasis. METHOD: Patients with hypochondriasis (n = 38), patients with anxiety disorders (n = 40), and healthy controls (n = 42) completed the Symptom and Outcomes Scale (SOS) measuring participants' estimation of the likelihood of various symptoms being indicative of a particular illness. Additionally, participants' general psychopathology (Brief Symptom Inventory), depressive (Beck Depression Inventory-II), and anxiety symptoms (Beck Anxiety Inventory) were evaluated. RESULTS: In comparison to patients with anxiety disorders and healthy controls, patients with hypochondriasis estimated bodily symptoms to be more likely an indicator for a catastrophic illness. Patients with anxiety disorders took a middle position between patients with hypochondriasis and healthy controls. Regarding the estimation of the likelihood of symptoms indicating a minor illness, no differences were found between the three groups. CONCLUSIONS: Dysfunctional beliefs about symptoms and illness are important and specific for patients with hypochondriasis, which is in line with the cognitive model. In order to reduce misinformation about serious illnesses in patients with hypochondriasis, more attention should be paid to psychoeducational strategies.

Reliability of adherence and competence assessment in psychoeducational treatment: influence of clinical experience.

For the evaluation of therapist competence in psychotherapeutic treatment, only highly experienced judges (experts) were found to be adequate, whereas therapist adherence could be assessed by nonexperts. Using experts implies high costs for the rating process. Therefore, an interesting question is whether experts are also necessary for the assessment of therapist adherence and competence in psychoeducational treatment. To test this, four judges evaluated therapist adherence and competence in 30 randomly selected videotaped sessions of manualized psychoeducation for recurrent depression. Two judges exhibited high clinical experience (experts) while two judges did not (novices). We could demonstrate that the novices were also able to evaluate therapists' adherence and competence in psychoeducative treatment with high reliability. Moreover, expert judgments were not more reliable than novice judgments. Adherence and competence ratings of experts and novices showed high concordance. These results carry implications in terms of reducing costs associated with the judgment process.