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Internet-based cognitive–behavioural therapy for severe health anxiety: randomised controlled trial

  • Erik Hedman (a1), Gerhard Andersson (a2), Erik Andersson (a1), Brjánn Ljótsson (a1), Christian Rück (a1), Gordon J. G. Asmundson (a3) and Nils Lindefors (a1)...
Abstract
Background

Hypochondriasis, characterised by severe health anxiety, is a common condition associated with functional disability. Cognitive–behavioural therapy (CBT) is an effective but not widely disseminated treatment for hypochondriasis. Internet-based CBT, including guidance in the form of minimal therapist contact via email, could be a more accessible treatment, but no study has investigated internet-based CBT for hypochondriasis.

Aims

To investigate the efficacy of internet-based CBT for hypochondriasis.

Method

A randomised controlled superiority trial with masked assessment comparing internet-based CBT (n = 40) over 12 weeks with an attention control condition (n = 41) for people with hypochondriasis. The primary outcome measure was the Health Anxiety Inventory. This trial is registrated with ClinicalTrials.gov (NCT00828152).

Results

Participants receiving internet-based CBT made large and superior improvements compared with the control group on measures of health anxiety (between-group Cohen's d range 1.52–1.62).

Conclusions

Internet-based CBT is an efficacious treatment for hypochondriasis that has the potential to increase accessibility and availability of CBT for hypochodriasis.

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Copyright
Corresponding author
Erik Hedman, M 46, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden. Email: erik.hedman.2@ki.se
Footnotes
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Declaration of interest

None.

Footnotes
References
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Internet-based cognitive–behavioural therapy for severe health anxiety: randomised controlled trial

  • Erik Hedman (a1), Gerhard Andersson (a2), Erik Andersson (a1), Brjánn Ljótsson (a1), Christian Rück (a1), Gordon J. G. Asmundson (a3) and Nils Lindefors (a1)...
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eLetters

Re: Internet-Based Cognitive Behavioural Therapy for Severe Health Anxiety: Randomised Controlled Trial

Erik Hedman, Licensed Psychologist, PhD.
15 July 2011

There were no statistically significant differences between the groups at pretreatment (as can be read from Table 2, means and standard deviations were very similar across groups). However, for several reasons we found it appropriate not to report p-values of baseline data. Analyses were conducted using ANCOVAs, holding pretreatment values as covariates. Moreover, when n is small, considerable variation between groups can be the case without reaching statistical significance, due to limited power. Consequently, several scientific journals, e.g. Annals of Internal Medicine (1), advise against the use of p-values when comparing baseline data in RCTs.

As for the name of the treatment, we view the term Internet-based cognitive behaviour therapy (CBT) as most suitable. The treatment’s theoretical foundation and its components are based on learning theory andcognitive theory. As stated in the Methods and the Discussion sections, the rationale for including a mindfulness exercise was to reduce avoidancebehaviours related to bodily sensations and to enhance exposure. Also, as the term CBT has been used for describing a plethora of treatments with substantial inter-treatment variability, the addition of “modified” would probably be misleading rather than clarifying. In fact, a recent paper presents mindfulness-based cognitive therapy as “a newer variation of cognitive behavioral therapy” (2).

Regarding control-group, I agree that participating in a discussion-forum hardly can be viewed as the optimal control condition. However, as the present study is the first ever to investigate Internet-based CBT for health anxiety, a comparison with conventional CBT would have been premature. Such a comparison would have meant conducting a non-inferioritytrial presenting difficulties regarding criteria for non-inferiority as well as the inherent assay sensitivity problem. In addition, far more participants would have needed to be randomised to Internet-based-CBT (dueto power issues), which would have been ethically questionable. That is, far more patients would have been exposed to a potentially non-effective or even unsafe treatment. As I see it, the ideal control condition would rather have been an Internet-based psychological placebo arm providing thesame amount of therapist attention and treatment credibility without targeting the central proposed mechanisms of change.

When it comes to recruitment, I consider advertisements and an article in a newspaper as two quite different forms of attention. The former is undercomplete control of the researcher while the latter isn’t. As a consequence, I find it reasonable to assume that the two forms of attention have differential effects in terms of recruitment and that they therefore should be reported separately.

As for generalizability of the findings, Dr Udo states that our paper tells us little as to whether Internet-based CBT works in acute psychiatrysettings or in an inpatient psychiatric context. I can only say that I absolutely agree. The clinic at which the present study was conducted is an outpatient clinic and Internet-based CBT is not different from conventional CBT in the sense that one should be vary cautions in generalizing findings from one health care context to another.

References

1 Annals of Internal Medicine. Instruction for Authors: Manuscript Preparation. http://www.annals.org/site/misc/ifora.xhtml. Retrieved 2011-07-07.

2 Dimidjian S, Davis KJ. Newer variations of cognitive-behavioral therapy:Behavioral activation and mindfulness-based cognitive therapy. Curr Psychiatry Rep 2009; 11: 453-8.

Declaration of interest: None.
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Conflict of interest: None Declared

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Internet-Based Cognitive Behavioural Therapy for Severe Health Anxiety: Randomised Controlled Trial

Itoro I. Udo, Specialty Registrar
17 June 2011

Dear Editor,

We read the above named article with interest. Having appraised the evidence, we write to comment as follows:

1.It is not possible, from the article(1), to tell whether the comparison group was similar to the experimental group as no statistical tests were done.

2.The treatment described by the authors as “Internet based CBT”, involved components of Mindfulness(1)and may have been more appropriately described as Internet based modified CBT.

3.Given that defined psychological approaches, including CBT are accepted as treatment for Health Anxiety (2-5), CBT delivered as usual, may have been more appropriate control treatment than online discussion forum. Online discussion forum is not recognisable or recommended treatment for health anxiety.

4.The description of subject recruitment is contradictory: “There were no advertisements in newspapers or in other media. However, an article about the study was published in a major nationwide newspaper.”

5.We note that the power in % is not stated explicitly in the study such as to inform respective clinician’s appraisal of this study as regards applicability of results to various clinical settings.

In light of the above, there is need for cautious interpretation of the evidence presented. We feel evidence as presented by this study is of limited therapeutic value in acute psychiatry settings, like crisis resolution home. treatment teams and inpatient psychiatry, that we work in.However we value this paper as adding to the limited body of knowledge available about treatments for Health Anxiety and expanding the notion that this disorder is treatable.

References:

1.Hedman E, Andersson G, Andersson E, Ljótsson B, Rück C, Asmundson GJG and Lindefors N. Internet-based Cognitive-Behavioural Therapy for Severe Health Anxiety: Randomised Controlled Trial. British Journal of Psychiatry 2011;98: 230-236

2.Warwick H. Cognitive Therapy in the Treatment of Hypochondriasis. Advances in Psychiatric Treatment 1998; 4: 285-291

3.Kroenke K, Swindle R. Cognitive-Behavioral Therapy for Somatization and Symptom Syndromes A Critical Review of Controlled Clinical Trials. Psychotherapy and Psychosomatics 2000; 69(4):205- 215.

4.Visser S, Bouman TK. The Treatment of Hypochondriasis: Exposure plus Response Prevention vs Cognitive Therapy. Behaviour Research and Therapy 2001; 39(4): 423-442.

5.Looper KJ, Kirmayer LJ. Behavioral Medicine Approaches to Somatoform disorders. Journal of Consulting and Clinical Psychology. 2002;70(3):810- 827.

Declaration of Interest: None.
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Conflict of interest: None Declared

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