Care, not Cure

Abstract & Commentary

Synopsis: This brief, individual CBT intervention, developed specifically to alter hypochondriacal thinking and restructure hypochondriacal beliefs, appears to have significant beneficial long-term effects on the symptoms of hypochondriasis.

Source: Barsky AJ, Ahern DK. JAMA. 2004;291:1464-1470.

This study recruited 187 patients from 2 large academic medical centers and from advertisements announcing a study "for health anxiety and hypochondriasis." To be included in the study, candidates had to score 150 or greater on the Whiteley Index and Somatic Symptom Inventory, and not to have major medical morbidity expected to worsen significantly for the next 12 months. These subjects were randomized to either usual care or to the cognitive behavioral therapy (CBT) group, and the seniority and practice volume of their primary care physicians was taken into account in this randomization process. Each patient’s primary physician received a letter explaining that the patient was in the study; the letter made 5 suggestions for medical management (quoted verbatim below):

1. Make improved coping with somatic symptoms rather than symptom elimination the goal of medical management;

2. Uncouple access to the physician from symptom status by scheduling regular appointments;

3. Provide only limited reassurance;

4. Explain the patient’s symptoms using the model of cognitive and perceptual symptoms amplification;

5. Be conservative in medical diagnosis and treatment, within the bounds of appropriate medical practice.

For the active treatment group, treatment consisted of 6 CBT sessions. These sessions occurred weekly, and lasted for 90 minutes. Each session was "tightly scripted," and focused on 1 of these 5 factors: attention and bodily hypervigilance, beliefs about symptom etiology, circumstances and context, illness and sick role behaviors, and mood. There were 3 study therapists involved, and all had advanced degrees and prior CBT experience. Patients were followed up at 6 and at 12 months after treatment. Outcome variables were a readministration of the Whitely Index,1 the Health Anxiety Inventory,2 the Hypochondriacal Cognitions Questionnaire, and the Somatic Symptom Inventory,3 and the Functional Status Questionnaire.4

Of the 187 total patients, 107 volunteered in response to the ad. These patients were "sicker" and more disabled than patients recruited from the physicians’ offices. One hundred-two patients were randomized to the treatment arm and 85 to the control arm. These groups did not differ by any important variable. The subjects were mostly middle-aged women with at least a decade of hypochodriacal symptoms. Only abut two-thirds of the active treatment group completed all 6 sessions.

For the CBT group, there were statistically significant improvements on most measures at 6 and 12 months of follow-up. Specifically, CBT patients had significant improvement in levels of hypochondriacal symptoms, beliefs, and attitudes, as well as health-related anxiety compared with the controls. They also had improvement in social functioning and intermediate activities of daily living compared to the control group. At 6 months, 20 of the CBT and 10 of the control patients had initiated psyhotropic medication or care with a mental health professional.

Comment by Barbara A. Phillips, MD, MSPH

Hypochondria is "morbid concern about one’s health especially when accompanied by delusions of physical disease."5 Barsky and Ahern do not tell us what symptoms these patients suffered from, but typical symptoms reported by hypochondriacs include insomnia and pain of all sorts, including headache, GI distress, and chest pain. These symptoms can be quite distressing both to patients and to their physicians, because they can be markers of serious pathology and warrant serious investigation. Physicians can begin to suspect that they are dealing with a hypochondriac when the patient is disappointed, rather than relieved, that the workup is negative (unfortunately, however, we all know horror stories of tumors missed and metabolic disorders overlooked by conscientious clinicians). Hypochondriacs are prevalent in primary care,6 and they are conspicuous consumers of health care resources.7 Any treatment that improves hypochondriacs’ ability to function and to cope with symptoms is likely to be cost effective. Thus, this paper is potentially quite significant, and it has already been widely discussed in the lay literature.

This paper interested me because, as a sleep specialist, I see many patients with difficulty sleeping. Although insomnia can be a manifestation of physical or psychiatric illness (and it is important to carefully address those issues) it is often a manifestation of hypochondriasis. For example, we know that women are much more likely to complain of sleeping problems than are men, even though objective measurement indicates that women actually sleep better than do men.8-10 Further, peri- and postmenopausal women sleep better (by objective measurement) than do premenopausal women, even though they are less satisfied with their sleep.11 For insomnia, it is likely that the response to the symptom, rather than the symptom itself, that is the major determinant of distress, quality of life, use of health care, and overall functioning. CBT aims to help the patient cope more effectively with sleeping problems; as the patient worries less about her inability to sleep, she does, in fact, often begin to sleep better. In the long run, CBT is at least as effective as are hypnotics for patients with insomnia.12 Barsky and Ahern note that with CBT, hypochondriacal attitudes improved more than symptoms did. In other words CBT improves coping with symptoms rather than curing the symptoms themselves—hence, "care rather than cure."

There are many problems with the application of CBT to patients with insomnia and other kinds of hypochondriasis. First and foremost, many patients with insomnia do not appreciate referral for CBT, preferring to have a more "medical" treatment. In the paper at hand, only about 30% of those patients who were eligible consented to enroll in the trial. Another problem, of course, is that insurance rarely pays for CBT, which confers the message that it is not "real" treatment, and also causes a financial barrier to access. Finally, experienced, effective CBT practitioners are not readily available in many communities.

So, how can we apply the lessons from this paper to the practice of internal medicine? Rules 1-5 (listed above) could be very powerful, even as a stand alone tool for hypochondriacs. To my way of thinking, patients with somatic symptoms may need to hear that there is a "good news, bad news" aspect to their complaints. The good news is that their insomnia, headache, chronic pain—or whatever—is not a harbinger of life-threatening illness; the bad news is that it might not be curable. Somatization is distressing for patients and for their physicians; both want a medical, scientific solution, and both are distressed and disappointed when there isn’t one. As physicians, we are sometimes frustrated with these patients, (and they with us!) and may dismiss their complaint, refer them to someone else, or order testing that we know is unnecessary instead of addressing the issue head on. In so doing, we may be missing the opportunity to care, even when we can’t cure.

Dr. Phillips, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington, KY, is Associate Editor of Internal Medicine Alert.

References

1. Pilowsky I. Br J Psychiatry. 1967;113:9-43.

2. Salkovskis PM, et al. Psychol Med. 2002;32:343-853.

3. Barsky AJ, et al. Arch Gen Psychiatry. 1990;47: 746-752.

4. Jette AM, et al. J Gen Intern Med. 1986;1:143-149.

5. www.dictionary.com (Merriam Webster). Accessed April 10, 2004.

6. Escobar JI, et al. Gen Hosp Psychiatry. 1998;20: 155-159.

7. Barsky AJ, et al. Med Care. 2001;39:705-715.

8. Hume KI, et al. J Sleep Res. 1998;7:85-94.

9. Dijk, DJ, et al. Sleep. 1989;12:500-507.

10. Ehlers CL, Kupfer DJ. Journal of Sleep Research. 1997:211-215.

11. Young T, et al. Sleep. 2003;26:667-672.

12. Smith MT, Haythornthwaite JA. Sleep Med Rev. 2004; 8:119-132.