Cognitive Therapy Versus Exposure Therapy for Hypochondriasis ...

Journal of Consulting and Clinical Psychology 2015, Vol. 83, No. 4, 665– 676

© 2014 American Psychological Association 0022-006X/15/$12.00 http://dx.doi.org/10.1037/ccp0000013

Cognitive Therapy Versus Exposure Therapy for Hypochondriasis (Health Anxiety): A Randomized Controlled Trial Florian Weck, Julia M. B. Neng, Samantha Richtberg, Marion Jakob, and Ulrich Stangier

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Goethe University 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.

What is the public health significance of this article? This study strongly suggests that both cognitive therapy and exposure therapy are effective treatments for hypochondriasis. Moreover, both treatments demonstrated large follow-up effect sizes, which was a deficit of former studies. Long-term efficacy might be achieved with the implementation of booster sessions.

Keywords: hypochondriasis, cognitive therapy, exposure therapy, illness anxiety disorder, treatment

In a recent literature review of 55 articles, the prevalence of hypochondriasis was found to be 0.40% (range ⫽ 0.0 –4.5%) in the general population and 2.95% (range ⫽ 0.3–8.5%) in general medical settings (Weck, Richtberg, & Neng, 2014). Hypochondriasis is associated with clinically significant distress, high persistence of the diagnosis, and high costs for the healthcare system (e.g., Fink, Ørnbøl, & Christensen, 2010). Fortunately, cognitive– behavioral therapy (CBT) has been demonstrated to be a highly effective approach for the treatment of hypochondriasis and health anxiety. In a recent meta-analysis that included 13 randomized controlled trials (RCTs) with a total sample size of 1,081 participants, CBT showed large effect sizes (Hedges’s g ⫽ 0.95) in comparison with control conditions on primary outcome measures (Olatunji et al., 2014). In that study, primary outcome measures were exclusively measures of hypochondriasis/health anxiety, which often include cognitive as well as behavioral aspects. CBT also has a positive effect on the comorbid depressive and anxiety symptoms (Olatunji et al., 2014; Thomson & Page, 2007) that frequently co-occur with hypochondriasis and health anxiety (e.g., Sunderland, Newby, & Andrews, 2013). Moreover, CBT has dem-

Hypochondriasis is characterized by fears of having a serious illness (e.g., cancer; American Psychiatric Association, 2000). While hypochondriasis describes the clinical syndrome, health anxiety refers to the full range of dysfunctional health concerns (see Marcus, Gurley, Marchi, & Bauer, 2007). Differences between hypochondriasis and health anxiety were found to be quantitative rather than qualitative (Ferguson, 2009; Longley et al., 2010). Therefore, empirical findings for hypochondriasis can be considered as relevant for health anxiety and vice versa.

This article was published Online First December 15, 2014. Florian Weck, Julia M. B. Neng, Samantha Richtberg, Marion Jakob, and Ulrich Stangier, Department of Clinical Psychology and Psychotherapy, Goethe University. This research was supported by Grants WE 4654/2-1 and WE4654/2-3 from the German Research Foundation. Correspondence concerning this article should be addressed to Florian Weck, Department of Clinical Psychology and Psychotherapy, Goethe University, Varrentrappstr, 40-42, 60486 Frankfurt am Main, Germany. E-mail: [email protected] 665


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onstrated lasting efficacy in follow-up analyses; however, effect sizes were significantly smaller than at posttreatment (Hedges’s g ⫽ 0.34; Olatunji et al., 2014). Furthermore, in one RCT that included 80 patients with hypochondriasis, CBT was superior to psychodynamic psychotherapy at reducing health anxiety and depressive symptoms (Sørensen, Birket-Smith, Wattar, Buemann, & Salkovskis, 2011). Even though there is evidence that CBT is highly effective in the treatment of hypochondriasis and health anxiety, it is unclear which interventions of CBT are the most promising as of yet (Thomson & Page, 2007). The prominent cognitive– behavioral model of hypochondriasis and health anxiety of Warwick and Salkovskis (1990) illustrates that the illnessrelated misinterpretation of bodily symptoms leads to an increased focus on the body, physiological arousal, and safety behaviors. Those bodily changes and behaviors strengthen the dysfunctional beliefs about one’s own illness, which in turn produces further physiological symptoms and safety behaviors, and so on. This circular model shows many similarities with cognitive– behavioral theories of anxiety disorders such as panic disorder (see Salkovskis & Clark, 1993). Processes such as safety behaviors, selective attention, and misinterpretations are specifically considered to be highly relevant for the maintenance of hypochondriasis and anxiety disorders. These common processes are also important for the conceptualization of psychological treatment approaches. Moreover, phenomenological similarities between hypochondriasis and anxiety disorders, such as a comparable level of anxiety, are strongly supported by empirical findings, with the strongest similarities found for panic disorder (e.g., Abramowitz, Olatunji, & Deacon, 2007; Deacon & Abramowitz, 2008; Gropalis, Bleichhardt, Witthöft, & Hiller, 2012; Hiller, Leibbrand, Rief, & Fichter, 2005; Neng & Weck, 2013; van den Heuvel et al., 2005; Weck, Bleichhardt, Witthöft, & Hiller, 2011; Weck, Neng, Richtberg, & Stangier, 2012). The phenomenological similarities between hypochondriasis and anxiety disorders are also important for choosing and developing effective treatment strategies (e.g., addressing anxiety with exposure). Because of the similarities between hypochondriasis and anxiety disorders, the perspective of hypochondriasis as a somatoform disorder instead of an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) was criticized and it was emphasized that as a result of this classification, “there has been a noticeable delay in the development of theoretically grounded paradigms for understanding and treating hypochondriasis” (Olatunji, Deacon, & Abramowitz, 2009; p. 482). When we take into account that hypochondriasis has much in common with anxiety disorders, exposure therapy (ET) can be considered an important approach for the treatment of hypochondriasis. While cognitive therapy (CT) has a focus on changing dysfunctional cognitions, ET is a behavioral treatment approach that includes the exposure of the patient to the feared object or situation to overcome the anxiety. Based on systematic investigations, the first evidence for the efficacy of ET was found in a randomized controlled pilot trial that included 17 patients with hypochondriasis (Bouman & Visser, 1998). In this study, a similar efficacy of ET and CT was found; however, no independent control group was used and the sample size was small. Subsequently, in a more comprehensive investigation by Visser and Bouman (2001), the efficacy of ET in compar-

ison with CT and a waiting list (WL) control group was investigated in 78 patients with hypochondriasis. Active treatments included 12 weekly sessions in a 3-month period. Treatment outcome was assessed four times (pretreatment, posttreatment, 1-month follow-up, and 7-month follow-up). ET and CT demonstrated their efficacy in comparison with the WL, but no differences were found between ET and CT on the main outcome measure (Illness Attitude Scales). However, on idiosyncratic scales (visual analogue scales) that evaluate cognitive aspects (i.e., the five main hypochondriacal cognitions of each individual patient, rated 0 –100% on conviction) and on depressive measures (Beck Depression Inventory), there was a trend that the improvement was larger in the CT group than in the ET group. Several limitations, however, restrict the generalizability of the findings. First, treatment integrity (i.e., therapists’ adherence and competence) was not evaluated, which limits the internal and external validity of the study (e.g., Perepletchikova, Treat, & Kazdin, 2007). Second, therapy outcome was only assessed by questionnaires and not by independent diagnosticians. Third, ET did not include exposure in sensu, which can be considered an important exposure-based intervention (Furer & Walker, 2005, 2008; Witthöft & Hiller, 2010). Fourth, there was a high dropout rate (28%), which calls into question the acceptability of the treatments, and only completers were included and no intention-to-treat analyses were conducted. Finally, the follow-up evaluation was administered only 7 months after treatment and a longer follow-up period would be desirable. Those limitations do not allow the satisfactory evaluation of the importance of cognitive approaches in comparison with behavioral approaches (i.e., exposure) for the treatment of hypochondriasis. On the other hand, the question of the role of cognitive versus behavioral interventions for the treatment of hypochondriasis is of high relevance for theoretical (e.g., maintenance of the disorder) and practical (e.g., treatment recommendations) reasons. Therefore, further research that considers cognitive approaches in comparison with behavioral approaches and that addresses the limitations of the previous studies is necessary. The aim of the current study was to investigate the efficacy of ET and CT compared with a control condition (i.e., WL) in a randomized controlled study design. We hypothesized that ET and CT would lead to a significant reduction in dysfunctional health-related cognitions and behaviors relative to the WL (Hypothesis 1). We hypothesized that both CT and ET would lead to a significant reduction in anxiety, depression, and bodily symptoms in comparison with the WL (Hypothesis 2). Moreover, we hypothesized that both CT and ET would demonstrate maintenance of treatment effects at the 12-month follow-up (Hypothesis 3). Regarding differences between CT and ET, we expected that CT would be more effective in changing hypochondriacal cognitions and that ET would be more effective in changing hypochondriacal behaviors (i.e., avoidance, reassurance seeking) at posttreatment (Hypothesis 4). In line with this hypothesis, previous research has found some evidence for the superiority of CT in reducing hypochondriacal cognitions (Visser & Bouman, 2001). However, in the long run it can be expected that differences between CT and ET are less pronounced because the reduction in dysfunctional health-related cognitions would lead to a reduction in health-related behavior and vice versa (see Warwick & Salkovskis, 1990).

COGNITIVE THERAPY VERSUS EXPOSURE THERAPY

Method

Participants were recruited between June 2010 and February 2013 from among treatment-seeking individuals at the outpatient unit of the Department of Clinical Psychology and Psychotherapy at the Goethe University Frankfurt in Germany. Information about the study was given in the local newspapers, on the radio, and via the Internet. Inclusion criteria of the current study were (a) age between 18 and 65 years, (b) meeting the DSM–IV criteria of hypochondriasis, (c) fluency and literacy in German, and (d) informed consent. Exclusion criteria were (a) a major medical illness (e.g., cancer), (b) acute suicidal tendencies, and (c) the clinical diagnosis of substance addiction, schizophrenia or schizoaffective disorder, or bipolar disorder according to the Structured Clinical Interview for DSM–IV (SCID; First, Spitzer, Gibbon, & Williams, 1997). If participants received psychotropic medica-

tions, they were required to have had a stable dose for at least five weeks prior to treatment. The participant flowchart is displayed in Figure 1. The 84 allocated participants ranged from 18 to 65 years old and had an average age of 40.05 (SD ⫽ 11.82) years. Fifty (59.52%) of the participants were female. The majority of the sample had qualifications for university entrance (64.29%) and was married or cohabiting (76.19%). Almost all participants were Caucasian (98.81%) and one patient was Latino. Participants declared that they suffered from health anxieties for a mean of 13.61 (SD ⫽ 12.37) years. The most feared diseases were cancer (67.86%), cardiovascular diseases (28.57%), infectious diseases (10.71%), and neurological diseases (9.52%). Forty-four (52.38%) of the participants had at least one comorbid disorder. Comorbid diagnoses were most often anxiety disorders, for which 30 (35.71%) of the participants met criteria (13 panic disorder, 10 specific phobia, five obsessive– compulsive disorder, two social phobia, and two

Enrollment

Completed telephone screening (n=320)

Completed face-to-face screening (n=135)

Excluded (n=185) - Not meeting inclusion criteria (n=128) - Declined participation (n=57)

Excluded (n=39) - Not meeting inclusion criteria (n=35) - Declined participation (n=4)

Completed SCID (n=96) Excluded (n=12) - Not meeting inclusion criteria (n=10) - Declined participation (n=2)

Allocated to CT (n=21) - drop-out (n=2)

Completed CT (n=19)

Post-treatment Assessment

Allocation

Randomized to Treatment (n=84)

Total CT completers ( n=35) Eligible for follow-up

Follow-up


Participants

Completed 12-month followup (n=30) - lost at follow-up (n=4)

Randomized to CT (n=17) - drop-out (n=1)

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Allocated to Wait List (n=42) - drop-out (n=7)

Completed Wait List (n=35)

No longer fulfilled the diagnosis of hypochondriasis after wait list (n=2)

Allocated to ET (n=21) - drop-out (n=2)

Completed ET (n=19)

Randomized to ET (n=16) - drop-out (n=2)

Total ET completers ( n=33) Eligible for follow-up

Completed 12-month followup (n=29) - lost at follow-up (n=4)

Figure 1. Flowchart of participants. CT ⫽ cognitive therapy; ET ⫽ exposure therapy; SCID ⫽ Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

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generalized anxiety disorder), and affective disorders, which 18 (21.43%) met criteria for. Fourteen (16.67%) of the participants received an antidepressant medication, most often a selective serotonin reuptake inhibitor (8.33%).


Measures Diagnoses. The SCID was used to establish the diagnoses. Experienced clinicians who were trained in a 2-day SCID workshop acted as diagnosticians. Diagnosticians were blind to the treatment status. All diagnostic interviews were video recorded. Twenty percent (n ⫽ 17) of the assessments were selected randomly and rated by a second diagnostician for information about reliability. The agreement between diagnosticians was high (␬ ⫽ .854; p ⬍ .001). Primary outcome measure. The Yale–Brown Obsessive Compulsive Scale for Hypochondriasis (H-YBOCS; Weck, Gropalis, Neng, & Witthöft, 2013) was used as the primary outcome measure because it has been demonstrated to be a reliable and valid clinical interview for the assessment of cognitions and behaviors in hypochondriasis. Assessors of the H-YBOCS were blind to the treatment status. The H-YBOCS is a 12-item clinicianadministered interview comprising three scales (cognitive, behavioral, and insight), each rated on a 5-point scale (0 – 4; response format depends on the question). One example item of the H-YBOCS is as follows: “Distress associated with thoughts related to illness.” In the current study, the cognitive scale (five items) and the behavioral scale (five items) of the H-YBOCS were used to assess dysfunctional health-related cognitions and behaviors. The interrater reliability (i.e., intraclass correlation coefficient [ICC]) of the H-YBOCS in the current study was evaluated on the basis of n ⫽ 30 video-recorded interviews and was ICC(2,2) ⫽ .97 for the cognitive and ICC(2,2) ⫽ .98 for the behavioral scales. Moreover, the cognitive (Cronbach’s alpha ⫽ .70) and the behavioral (Cronbach’s alpha ⫽ .73) scales of the H-YBOCS demonstrated satisfactory internal consistency in the current study. Secondary outcome measures. Several standardized selfreport measures were used for the evaluation of hypochondriacal characteristics and general psychopathology. Illness Attitudes Scales (IAS; Kellner, 1986; German version: Hiller, Rief, & Fichter, 2002). The IAS consists of 27 items (e.g., “Do you worry about your health?”), each rated on a 5-point rating scale, ranging from 0 (no) to 4 (most of the time). The IAS is an internationally well-established questionnaire for the assessment of hypochondriacal attributes that has demonstrated good reliability and validity (Sirri, Grandi, & Fava, 2008). The IAS had high internal consistency in the current study (Cronbach’s alpha ⫽ .87). Cognitions About Body and Health Questionnaire (CABAH; Rief, Hiller, & Margraf, 1998). The CABAH was used for the assessment of cognitions that are relevant for the maintenance of hypochondriasis (e.g., “Bodily complaints are always a sign of disease”). The items of the CABAH are rated on a 4-point scale, ranging from 0 (completely wrong) to 3 (completely right). We used a 28-item version of the CABAH (items of the subscale health habits were excluded because they failed to demonstrate validity; Rief et al., 1998), which showed good reliability and

validity. The CABAH demonstrated high internal consistency in the current study (Cronbach’s alpha ⫽ .86). Questionnaire for Assessing Safety Behavior in Hypochondriasis/Health Anxiety (QSBH; Weck, Brehm, & SchermellehEngel, 2012). The QSBH was used for the assessment of hypochondriacal safety behaviors (reassurance and avoidance). An example item of the QSBH is as follows: “Do you check if you look healthy in the mirror?” The QSBH consists of 16 items, each rated on a 5-point rating scale, ranging from 0 (never) to 4 (very frequently). In the current study, the internal consistency of the QSBH was Cronbach’ s ␣ ⫽ .78. Patient Health Questionnaire (PHQ-15; Spitzer, Kroenke, & Williams, 1999; German version: Löwe, Spitzer, Zipfel, & Herzog, 2002). The PHQ-15 was used for the evaluation of 15 somatoform symptoms (assessed by 13 items; e.g., “headache”), each rated on a 3-point rating scale, ranging from 0 (not bothered at all) to 2 (bothered a lot). In the current study, the internal consistency of the PHQ-15 was Cronbach’s alpha ⫽ .78. Beck Depression Inventory-II (BDI-II; Beck & Steer, 1996; German version: Hautzinger, Keller, & Kühner, 2006). The BDI-II was used for the evaluation of depressive symptoms. The instrument consists of 21 items. In the current study, the internal consistency of the BDI-II was Cronbach’s alpha ⫽ .87. Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988; German version: Margraf & Ehlers, 2007). The BAI is a 21-item questionnaire that was used for the assessment of anxiety symptoms. In the current study, the Cronbach’s alpha of the BAI was .92.

Procedures This trial was registered at ClinicalTrials.gov (NCT01119469). The study protocol was approved by the Institutional Review Board of the University Hospital Frankfurt and written informed consent was given by all participants. Potential study candidates were screened via telephone and a face-to-face interview for the criteria of a DSM–IV diagnosis of hypochondriasis (American Psychological Association, 2000) and the inclusion/exclusion criteria. Persons who reported symptoms in line with the DSM–IV criteria for hypochondriasis and who met the inclusion criteria received a diagnostic interview using the SCID. Eligible participants were randomly assigned to CT, ET, or the WL (1:1:2). Participants who were assigned to the WL were randomized afterward to CT or ET (see Figure 1).

Interventions Both treatments included 12 regular sessions (attended weekly) and three booster sessions (applied 1, 3, and 6 months after the last regular treatment session), each lasting 50 min. The CT and ET interventions are described in detail in a treatment manual. Treatments were conducted by 27 Master’s degree clinical psychologists (22 females and five males) who had a mean of 2.62 (SD ⫽ 1.09; range ⫽ 1.4 –6.6) years of clinical experience after their Master’s degree. Most (24; 88.98%) of the therapists were in psychotherapy training and three (11.11%) were licensed psychotherapists. Therapists were trained via workshops for a total of 24 hr in the underlying theory and practical elements of the treatment using videotapes and role playing. Therapists received regular



supervision at least once per month by F.W. (ET) and U.S. (CT), who are both experts in the administered treatments. Cognitive therapy (CT). CT aimed to change the cognitive processes that are considered relevant for the maintenance of heath anxieties (i.e., selective attention to bodily symptoms, dysfunctional beliefs about symptoms and illnesses). Session 1 included information about the clinical picture of hypochondriasis (e.g., criteria of hypochondriasis, continuum of health anxieties, possible risk factors). Information was given that common physical sensations (e.g., a tingling sensation) could enter awareness through selective attention and could then become the object of health anxieties. In Sessions 2 and 3, behavioral experiments were used to demonstrate the importance of selective attention to bodily symptoms for the maintenance of health anxieties. An idiosyncratic model based on information processing in hypochondriasis was established. Attention-related exercises were used to shift attention from internal bodily sensations to external auditory stimuli (see Papageorgiou & Wells, 1998). Sessions 4 to 11 focused on the reduction of dysfunctional health-related beliefs and included the following interventions: psychoeducation (e.g., information about the autonomic nervous system), cognitive restructuring of dysfunctional health-related automatic thoughts and beliefs, behavioral experiments to demonstrate the negative aspects of safety behaviors, and imagery rescripting for the modification of intrusive images. A more detailed description of the interventions is given elsewhere (Weck, 2014). Session 12 focused on relapse prevention and included a discussion of how to establish techniques for the time after treatment. Exposure therapy (ET). ET aimed to expose the patients to stimuli that are relevant for health anxieties (e.g., documentaries about diseases) and to reduce avoidance behaviors (e.g., avoiding funerals) and safety behaviors (e.g., reassurance by doctors, checking the abdomen for cancer). As in CT, Session 1 included information about the clinical picture of hypochondriasis. The roles of avoidance and safety behaviors for the maintenance of health anxieties were discussed with the patient. Sessions 2 to 4 focused on the reduction of safety behaviors (i.e., body checking, reassurance, and doctor visits). Patients were to reduce their safety behaviors step-by-step. Occurring problems were discussed with the therapist. Sessions 5 to 11 included the implementation of the treatment rationale for exposure (i.e., exposure to health-related stimuli, without using safety behaviors, leads to a reduction of health anxieties). Exercises of exposure included interoceptive exposure (e.g., hyperventilation), exposure in vivo (e.g., viewing documentaries about illness), and exposure in sensu (e.g., being confronted with images of being ill and one’s own death; see Furer & Walker, 2008, 2005). A more detailed description of the intervention is given elsewhere (Weck, Ritter, & Stangier, 2012). As in CT, Session 12 focused on relapse prevention and included the discussion on how to use exposure techniques for the time after treatment. Wait list (WL). After 3 months, participants received a diagnostic interview (i.e., SCID and H-YBOCS) and completed the self-report measures.

Treatment Integrity Therapy sessions of all patients who started treatment were included in the evaluation of therapists’ adherence and compe-

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tence. A total of 150 videotaped therapy sessions (76 of CT and 74 of ET) were each rated by two Master’s level clinical psychologists. Raters received a 20-hr training course on how to apply the adherence and competence scales by evaluating and discussing therapy sessions that were not part of the current study. For each patient, two treatment sessions (Sessions 3 and 7 for CT and Sessions 3 and 8 for ET) were selected for the evaluation of therapists’ adherence and competence. Therapists’ adherence. Therapists’ adherence was rated with a 17-item rating scale that aimed to evaluate whether specific interventions described in the treatment manuals were applied during the treatment sessions. The adherence scale has a 3-point rating scale (0 ⫽ not adherent, 1 ⫽ partly adherent, and 2 ⫽ adherent) and consists of nine items that evaluate aspects of adherence that are intended in both treatment conditions (agenda, time management, use of materials, setting homework, reviewing homework, giving information, identification of safety behaviors, reduction of safety behaviors, and relapse prophylaxis). Three items are intended only in ET but are forbidden in CT (giving a rationale for exposure, developing an anxiety hierarchy, guiding exposure exercises) and four items are intended only in CT but are forbidden in ET (elaborating a cognitive model of hypochondriasis, attention-related exercises, guiding behavior experiments, and modification of automatic thoughts). One item is forbidden in both treatment conditions (interventions from other therapeutic approaches, such as psychodynamic interventions). The interrater reliability between the two raters of the mean score of all 17 adherence items was high, ICC(2,2) ⫽ .78; p ⬍ .001. The mean score of intended interventions was high (CT: M ⫽ 1.67; SD ⫽ 0.24; ET: M ⫽ 1.67; SD ⫽ 0.20), and the mean score of forbidden interventions was low (CT: M ⫽ 0.11; SD ⫽ 0.21; ET: M ⫽ 0.06; SD ⫽ 0.13) in both treatments. The purity index (Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985), which reflects the ratio of the intended interventions to the presence of intended plus unintended interventions, was 0.94 (SD ⫽ 0.10) in CT and 0.96 (SD ⫽ 0.07) in ET, which is very high. Therapists’ competence. Therapists’ competence was evaluated with the Cognitive Therapy Scale (CTS; Young & Beck, 1980; German version: Weck, Hautzinger, Heidenreich, & Stangier, 2010). The scale format of the CTS is a 7-point rating scale (0 ⫽ poor, 1 ⫽ barely adequate, 2 ⫽ mediocre, 3 ⫽ satisfactory, 4 ⫽ good, 5 ⫽ very good, and 6 ⫽ excellent). The German version of the CTS consists of 14 items (agenda setting, dealing with problems/questions/objections, clarity of communication, pacing and efficient use of time, interpersonal effectiveness, resource activation, reviewing previously set homework, using feedback and summaries, guided discovery, focus on central cognitions and behavior, rationale, selecting appropriate strategies, appropriate implementation of techniques, and assigning homework). The interrater reliability of the CTS mean score between the two raters was high, ICC(2,2) ⫽ .79; p ⬍ .001. Treatments in the CT (M ⫽ 3.80; SD ⫽ 0.81) and ET (M ⫽ 3.62; SD ⫽ 0.74) conditions did not differ significantly in the level of competence in the CTS mean score, F(1,76) ⫽ 1.94; p ⫽ .17. According to Shaw et al. (1999), the level of competence is satisfactory in both treatments.


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Statistical Analyses Analyses were conducted with both the completer (N ⫽ 73) and the intent-to-treat (ITT) sample (N ⫽ 84). When addressing missing data, last observations were carried forward. The results of ITT analyses are reported in the text and results of completer analyses are only reported when they differ from the ITT analyses. The results of ITT and completer analyses are displayed in Tables 1 and 2. In preliminary analyses, a series of analyses of variance (ANOVAs) and chi-square analyses were conducted to analyze possible differences in pretreatment symptoms and demographic characteristics. A priori power analyses were conducted using GⴱPower (Faul, Erdfelder, Buchner, & Lang, 2009). In meta-analyses, large effect sizes were found between psychotherapy and WL control groups (Olatunji et al., 2014; Thomson & Page, 2007). To detect a large effect (.80) at a power of 1 – ␤ ⫽ 0.90 with an ␣ of .05, a sample of at least 83 participants is needed. We used a two-stage strategy for the data analyses of treatment effects. In the first stage, analyses of covariance (ANCOVAs) with posttreatment scores as the dependent variable, pretreatment scores as a covariate, and group (CT, ET, and WL) as the independent variable were conducted. Differences between the three conditions during each treatment phase were investigated with post hoc comparisons. In the second stage, repeated analyses of variance (ANOVAs)1 with two groups (CT and ET) and three times (pre, post, and follow-up) were conducted. Those analyses also included the participants who were initially allocated to the WL and subsequently randomized to the active treatment conditions.

Results Preliminary Analyses No significant differences between the three groups (CT, ET, and WL) were found for sociodemographic variables or other diagnoses: sex (p ⫽ .641), age (p ⫽ .337), educational level (p ⫽ .943), and number of comorbid diagnoses (p ⫽ .348). No differences were found between the groups in the number of dropouts (p ⫽ .625) or the taking of antidepressant medication (p ⫽ .152). We found no significant difference between the groups on any outcome variable at pretreatment for the whole sample (N ⫽ 84): H-YBOCS cognitive (p ⫽ .111), H-YBOCS behavioral (p ⫽ .812), IAS (p ⫽ .569), CABAH (p ⫽ .836), QSBH (p ⫽ .463), PHQ-15 (p ⫽ .660), BDI-II (p ⫽ .263), and BAI (p ⫽ .284). Furthermore, no significant differences were found between the CT and ET group for the patients who were considered in the second stage analyses (N ⫽ 68) in the pretreatment outcome measures: H-YBOCS cognitive (p ⫽ .827), H-YBOCS behavioral (p ⫽ .428), IAS (p ⫽ .737), CABAH (p ⫽ .693), QSBH (p ⫽ .256), PHQ-15 (p ⫽ .248), BDI-II (p ⫽ .577), and BAI (p ⫽ .382).

Comparison Between Cognitive Therapy, Exposure Therapy, and Wait List Primary outcome measures. ANCOVAs revealed a significant main effect of treatment group on the cognitive and behavioral subscales of the H-YBOCS (see Table 1). Post hoc pairwise comparisons of the posttreatment scores of the cognitive subscale

showed significant differences between CT and the WL (p ⬍ .001) and between ET and the WL (p ⬍ .001), but not between CT and ET (p ⫽ .756). Post hoc pairwise comparisons of the posttreatment scores of the behavioral subscale showed significant differences between CT and the WL (p ⫽ .002) and between ET and the WL (p ⬍ .001), but not between CT and ET (p ⫽ .440). Secondary outcome measures. ANCOVAs revealed a significant main effect of treatment group on all secondary outcome measures (see Table 1). Post hoc pairwise comparisons for posttreatment scores for all measures showed significant differences between CT and the WL and between ET and the WL, but not between CT and ET. However, for the BAI, differences between CT and the WL were only significant by trend (p ⫽ .074).

Comparison Between Cognitive Therapy and Exposure Therapy for the Outcomes at Posttreatment and Follow-up Primary outcome measures. The results are shown in Table 2. For the cognitive subscale of the H-YBOCS, there was a significant main effect of time, F(2, 66) ⫽ 80.98; p ⬍ .001, but not of group, F(1, 66) ⫽ 0.31; p ⫽ .582, or of the Time ⫻ Group interaction, F(2, 66) ⫽ 0.5; p ⫽ .954. For the behavioral subscale, there was a significant main effect of time, F(2, 66) ⫽ 54.87; p ⬍ .001, but not of group, F(1, 66) ⫽ 0.00; p ⫽ .968, or of the Time ⫻ Group interaction, F(2, 66) ⫽ 1.51; p ⫽ .226. Pre-follow-up effect sizes were large for the cognitive subscale (CT: Hedges’s g ⫽ 1.67; ET: Hedges’s g ⫽ 1.64) as well as for the behavioral subscale (CT: Hedges’s g ⫽ 1.43; ET: Hedges’s g ⫽ 1.56) of the H-YBOCS. We also computed the effect sizes between CT and ET for the subsample of patients with a comorbid anxiety disorder (n ⫽ 23). For the cognitive subscale of the H-YBOCS, the Hedges’s gs were 0.00 at post as well as at follow-up. For the behavioral subscale of the H-YBOCS, the Hedges’s gs were 0.48 at post and ⫺0.29 at follow-up. No significant Time ⫻ Group interactions were found. Secondary outcome measures. For all secondary measures, there was a significant main effect of time, but no significant group effect nor significant Time ⫻ Group interactions. Only in the completer analyses was a significant Time ⫻ Group interaction found for the QSBH (p ⫽ .010). This indicates a trend of a larger reduction in hypochondriacal safety behaviors in the ET group than in the CT group. Pre-follow-up effect sizes were large for most of the secondary outcome measures for CT (IAS: Hedges’s g ⫽ 1.31; CABAH: Hedges’s g ⫽ 1.07; QSBH: Hedges’s g ⫽ 0.92; PHQ-15: Hedges’s g ⫽ 0.86; BAI: Hedges’s g ⫽ 0.72; BDI-II: Hedges’s g ⫽ 1.00) as well as for ET (IAS: Hedges’s g ⫽ 1.38; CABAH: Hedges’s g ⫽ 0.98; QSBH: Hedges’s g ⫽ 1.05; PHQ-15: Hedges’s g ⫽ 0.50; BAI: Hedges’s g ⫽ 0.51; BDI-II: Hedges’s g ⫽ 0.56). We also computed the effect sizes for the secondary outcome measures between CT and ET for the subsample of patients with a comorbid anxiety disorder (n ⫽ 23) at post (IAS: Hedges’s 1 Repeated ANOVAs that included the level of therapist competence (CTS mean score) as a covariate are alternative methods of analysis that were also conducted and revealed identical results. Thus, we found no significant interaction between Time ⫻ Group or between Time ⫻ Level of competence.

6.05 (2.99) 3.95 (3.31) 49.40 (16.76) 23.78 (9.17) 22.44 (8.69) 6.50 (3.49) 13.94 (7.78) 7.28 (6.77)

70.79 (15.30) 33.19 (8.94) 30.79 (9.16) 9.25 (4.49) 20.44 (13.15) 13.67 (7.33)

53.89 (19.21) 27.19 (12.69) 23.05 (9.14) 6.67 (3.71) 14.67 (8.10) 8.00 (7.52)

71.97 (15.39) 35.25 (10.54) 30.20 (9.51) 9.02 (4.55) 20.24 (12.58) 13.48 (7.76)

12.11 (2.42) 9.63 (3.08)

6.43 (3.33) 4.76 (4.21)

Post

11.90 (2.70) 9.90 (3.24)

Pre

Post

53.35 (16.71) 22.21 (9.24) 21.10 (10.97) 5.94 (4.04) 10.90 (10.73) 5.71 (5.51)

5.95 (3.33) 3.52 (3.93)

71.14 (14.64) 33.74 (11.77) 32.14 (12.95) 8.21 (4.09) 16.05 (11.92) 11.27 (7.77)

10.21 (3.19) 9.17 (3.88) 50.80 (15.02) 21.54 (8.94) 20.32 (11.27) 5.88 (4.25) 10.78 (11.06) 5.32 (5.65)

5.53 (3.52) 2.94 (3.61)

Pre

75.08 (14.13) 35.35 (10.54) 33.53 (9.30) 7.89 (5.15) 19.70 (12.07) 14.67 (8.58)

74.30 (15.05) 33.50 (11.10) 33.20 (9.87) 7.57 (5.07) 19.61 (12.47) 14.84 (8.89)

11.50 (3.07) 10.32 (3.76)

Post

71.62 (15.23) 32.41 (9.28) 33.82 (10.00) 7.91 (5.26) 18.41 (12.75) 12.77 (8.57)

10.24 (4.12) 8.50 (5.01)

72.84 (14.44) 33.36 (9.25) 34.05 (9.40) 8.19 (5.29) 18.70 (12.33) 12.95 (8.31)

10.62 (4.21) 8.43 (4.96)

WL M (SD)

11.90 (2.70) 10.07 (3.90)

Completer sample (N ⫽ 73)

71.41 (14.99) 33.24 (11.67) 31.80 (12.34) 8.04 (3.92) 15.67 (11.59) 11.10 (7.39)

10.19 (3.04) 9.43 (3.85)

Intention-to-treat sample (N ⫽ 84)

Pre

ET M (SD)

21.36 13.71 21.08 4.61 2.96 7.53

14.04 13.08

19.07 12.36 21.72 5.30 3.33 7.61

13.46 10.46

F

1.11 1.01 1.41 0.93 1.19 0.30 0.49 0.79

⬍.001 ⬍.001 ⬍.001 .013 .059 .001

1.17 0.59 1.18 0.31 0.36 0.61

⬍.001 ⬍.001 ⬍.001 .007 .041 .001

⬍.001 ⬍.001

1.06 0.78

CT–WL

1.37 1.19 1.28 0.42 0.67 1.01

1.21 1.24

1.27 1.21 1.29 0.46 0.66 0.98

1.20 1.07

ET–WL

Hedges’s g

⬍.001 ⬍.001

p

ANCOVA

Note. CT ⫽ cognitive therapy; ET ⫽ exposure therapy; WL ⫽ wait list; ANCOVA ⫽ analyses of covariance; Pre ⫽ pretreatment; Post ⫽ posttreatment; H-YBOCS ⫽ Yale–Brown Obsessive Compulsive Scale for Hypochondriasis; IAS ⫽ Illness Attitudes Scales; CABAH ⫽ Cognitions About Body and Health Questionnaire; QSBH ⫽ Questionnaire for Assessing Safety Behavior in Hypochondriasis/Health Anxiety; PHQ-15 ⫽ Patients Health Questionnaire; BAI ⫽ Beck Anxiety Inventory; BDI-II ⫽ Beck Depression Inventory II.

Primary outcome measure H-YBOCS Cognitive Behavioral Secondary outcome measures IAS CABAH QSBH PHQ-15 BAI BDI-II


Measures

CT M (SD)

Table 1 Mean Scores and Standard Deviations of Primary and Secondary Outcome Measures at Pre- and Posttreatment, Results of the Analyses of Covariance, and Effect Sizes of the Intention-to-Treat and Completer Samples



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6.20 (2.54) 5.30 (3.73) 48.31 (16.96) 23.23 (7.56) 23.56 (8.09) 5.41 (2.82) 9.50 (6.06) 6.04 (5.19)

67.84 (14.30) 30.38 (8.30) 30.55 (9.73) 7.68 (4.12) 14.71 (9.26) 12.92 (6.30)

53.18 (18.13) 25.30 (9.64) 24.38 (8.36) 6.14 (3.07) 12.11 (7.65) 7.09 (5.90)

71.04 (15.82) 32.90 (9.17) 31.72 (9.35) 8.75 (4.35) 18.57 (12.04) 13.14 (6.66)

10.87 (3.07) 8.27 (4.05)

6.57 (2.92) 5.34 (3.90)

Post

11.06 (3.11) 8.80 (4.08)

Pre

Pre

72.26 (13.80) 33.88 (11.09) 34.71 (12.09) 7.47 (4.72) 16.90 (12.53) 11.49 (8.74)

10.88 (3.59) 9.61 (4.25)

39.88 (17.23) 18.81 (7.86) 21.14 (10.43) 4.33 (2.99) 7.96 (7.14) 5.46 (5.66)

4.80 (3.32) 2.57 (3.72) 69.38 (12.96) 32.70 (10.95) 33.48 (11.51) 6.66 (4.65) 14.15 (10.03) 10.17 (7.77)

10.90 (3.54) 9.21 (4.35)

Completer sample (N ⫽ 60)

47.39 (20.22) 22.27 (10.64) 22.73 (10.16) 5.40 (3.39) 11.06 (8.62) 6.69 (6.26)

5.37 (3.69) 3.00 (4.03)

Post

44.85 (14.03) 19.27 (7.84) 19.45 (10.39) 3.69 (2.87) 7.34 (8.38) 5.00 (6.51)

6.03 (3.53) 3.79 (3.68)

53.63 (18.18) 23.46 (11.57) 23.88 (11.30) 5.40 (4.55) 11.44 (12.46) 7.58 (8.51)

6.18 (3.60) 4.15 (3.89)

Intention-to-treat sample (N ⫽ 68)

12-month

ET M (SD)

36.06 (16.71) 17.78 (10.83) 16.50 (10.67) 3.46 (2.48) 6.50 (5.95) 3.70 (5.00)

4.59 (3.52) 2.83 (3.51)

47.39 (21.52) 22.16 (12.88) 21.97 (12.17) 5.18 (4.44) 10.75 (11.78) 6.82 (8.02)

4.91 (3.68) 3.30 (3.84)

12-month

0.73 2.69 4.91 0.35 0.21 0.36

0.03 1.84

0.05 0.95 2.06 0.77 0.28 1.32

0.05 1.51

F

.483 .074 .010 .708 .812 .700

.970 .163

.951 .389 .132 .464 .754 .271

.954 .226

p

Interaction

0.22 0.51 0.44 0.60 0.30 0.18

0.23 0.11 0.44 0.32 0.22 0.33

0.06 ⫺0.07

0.00 0.01 0.07 0.06 0.03 ⫺0.02

⫺0.02 0.17 0.05 0.19 0.07 ⫺0.07

0.06 0.41

0.12 ⫺0.08

12-month

0.12 0.31

Post

Hedges’s g ET-CT

Note. CT ⫽ cognitive therapy; ET ⫽ exposure therapy; WL ⫽ wait list; ANCOVA ⫽ analyses of covariance; Pre ⫽ pretreatment; Post ⫽ posttreatment; 12-month ⫽ 12 month follow-up; H-YBOCS ⫽ Yale–Brown Obsessive Compulsive Scale for Hypochondriasis; IAS ⫽ Illness Attitudes Scales; CABAH ⫽ Cognitions About Body and Health Questionnaire; QSBH ⫽ Questionnaire for Assessing Safety Behavior in Hypochondriasis/Health Anxiety; PHQ-15 ⫽ Patients Health Questionnaire; BAI ⫽ Beck Anxiety Inventory; BDI-II ⫽ Beck Depression Inventory II.



Measures

CT M (SD)

Table 2 Mean Scores and Standard Deviations of Primary and Secondary Outcome Measures at Pre-, Posttreatment, and Follow-up; Results of the Repeated Analyses of Variance; and Effect Sizes of the Intention-to-Treat and Completer Samples


672 WECK, NENG, RICHTBERG, JAKOB, AND STANGIER


g ⫽ ⫺0.12; CABAH: Hedges’s g ⫽ ⫺0.07; QSBH: Hedges’s g ⫽ 0.17; PHQ-15: Hedges’s g ⫽ ⫺0.12; BAI: Hedges’s g ⫽ 0.24; BDI-II: Hedges’s g ⫽ 0.36) and at follow-up (IAS: Hedges’s g ⫽ ⫺0.09; CABAH: Hedges’s g ⫽ ⫺0.32; QSBH: Hedges’s g ⫽ ⫺0.06; PHQ-15: Hedges’s g ⫽ ⫺0.38; BAI: Hedges’s g ⫽ 0.05; BDI-II: Hedges’s g ⫽ 0.50). No significant Time ⫻ Group interactions were found.


Discussion In the current study, ET and CT were shown to be highly effective approaches for the treatment of patients with hypochondriasis. Both approaches led to significant improvements by reducing hypochondriacal cognitions and behaviors in comparison with the WL (Hypothesis 1). Depressive symptoms and bodily complaints were reduced significantly by ET and CT, but we found that anxiety symptoms were reduced significantly in ET and only by trend in CT (Hypothesis 2). Treatment effects were maintained in the CT and ET groups at the 12-month follow-up investigation (Hypothesis 3). We found no differences between CT and ET in the primary outcome measures. In the secondary outcome measures, we found a larger reduction in safety behaviors in the ET group than in the CT group in the completer analyses (but not in the ITT analyses; Hypothesis 4). The current study addressed several limitations of previous studies that investigated the efficacy of ET for hypochondriasis. First, treatment integrity was evaluated; therapists’ adherence to the treatment manuals was high and the level of competence was satisfactory according to Shaw et al. (1999). Second, therapy outcomes were assessed by an independent and blind diagnostician with a reliable standardized interview, namely the H-YBOCS. Third, ET included exposure in sensu, which can be considered an important intervention for the treatment of health anxieties. Fourth, ITT as well as completer analyses were conducted. Finally, the follow-up period was expanded to 12 months. In the current study, most effect sizes of the primary and secondary outcome measures were large regarding the reduction of hypochondriacal symptoms: CT versus WL (Hedges’s g ⫽ 0.59 –1.18) and ET versus WL (Hedges’s g ⫽ 1.07–1.29). This is in line with meta-analyses, which found a mean effect size of 0.86 and 0.95 in RCTs investigating psychotherapy for hypochondriasis and health anxiety (Olatunji et al., 2014; Thomson & Page, 2007). The large improvement in depressive and anxiety symptoms and the moderate improvement in physical symptoms in the current study are also consistent with the meta-analyses. Olatunji et al. (2014) found only moderate effect sizes for CBT in their follow-up investigations of the treatment of hypochondriasis and health anxiety (Hedges’s g ⫽ 0.34). In contrast with this meta-analysis, we found large Pre-follow-up effect sizes for CT as well as for ET for the primary outcome measures (Hedges’s g ⫽ 1.43–1.67). One possible explanation for this differing finding might be the implementation of booster sessions in the current study. Booster sessions were suggested by Olatunji et al. as an opportunity for sustaining treatment gains in follow-up investigations. Future studies should systematically investigate whether booster sessions are able to ensure maintenance of therapy effects in the treatment of health anxiety. In contrast to the study by Visser and Bouman (2001), we found no evidence that patients in CT showed larger improvements in

673

dysfunctional cognitions or depressive symptoms. Instead, we found a trend that anxiety symptoms only improved with ET and that safety behaviors improved more with ET than with CT. The differences regarding the reduction of safety behavior might be especially essential because experimental investigations have demonstrated that safety behaviors (e.g., seeking reassurance, checking your body in the mirror for moles) are an important risk factor for the development and maintenance of health anxiety (e.g., Abramowitz & Moore, 2007; Olatunji, Etzel, Tomarken, Cieslielski, & Deacon, 2011). However, we found significant differences only in the completer analyses but not in the ITT analyses, and moreover, we found no differences between CT and ET in the primary outcome measures. Therefore, results should be interpreted with caution. When we only considered the subsample of patients with a comorbid anxiety disorder, we found somewhat differing effect sizes between CT and ET than in the whole sample. For example, differences in the cognitive subscale became smaller and differences in the behavioral subscale of the H-YBOCS became larger. However, these effect sizes should be considered cautiously because we found no significant Time ⫻ Group interactions and the sample size was small (n ⫽ 23). Nonetheless, the different findings for patients with comorbid anxiety disorders might be important regarding a differential indication for CT and ET and should therefore be tested in future studies. A further interesting finding is that ET, which included no formal cognitive restructuring, leads to such clear changes in dysfunctional health-related cognitions. Similar results are reported for the treatment of obsessive– compulsive disorder. There, changes in cognitions occur in exposure therapy, even though cognitive change was not the aim of the treatment (Solem, Håland, Vogel, Hansen, & Wells, 2009). The clear efficacy of ET for hypochondriasis also shows the close relationship between hypochondriasis and anxiety disorders. Considering the clinical implications of the current study, CT and ET can be seen as effective treatment approaches for patients with hypochondriasis. However, specific cognitive interventions (e.g., cognitive restructuring) do not seem to be a necessary condition for achieving cognitive changes. In our study, we generally found higher effect sizes of ET than of CT, and a trend for superiority of ET over CT for the reduction of anxiety and safety behaviors was found. Moreover, effect sizes indicate that safety behaviors (behavioral subscale of the H-YBOCS) seem to change faster in ET than in CT (particularly when only including patients with a comorbid anxiety disorder). Therefore, on the basis of the current study, ET can be recommended as the preferential treatment approach, especially when patients have a comorbid anxiety disorder. The current study has many strengths, but aspects that limit generalizability of the findings should also be considered. First, patients in the current study were seeking psychological treatment for their health anxieties. However, patients with hypochondriasis often seek medical treatment for their problems. Therefore, the participants might have responded more than patients who remain in medical settings would. Second, 7.9% of the patients in CT and 10.8% in ET were dropouts. Therefore, the treatment was not accepted by all patients. However, in some previous RCTs, the dropout rate was substantially higher, for example, 28.3% in the study by


674


Visser and Bouman (2001) and 25.0% in the study by Greeven et al. (2007). Therefore, acceptability of both of our approaches can be considered to be satisfactory. Comparably low dropout rates were also found in some other RCTs (e.g., Clark et al., 1998; McManus, Surawy, Muse, Vazquez-Montes, & Williams, 2012) and underline the suitability of cognitive and behavioral interventions for health anxiety. Third, half of the participants (52%) had a comorbid disorder and it can be questioned whether the findings can be generalized to patients without comorbid disorders. On the other hand, such high rates of comorbidity are typical for patients with hypochondriasis/health anxiety (e.g., Barsky, Wyshak, & Klerman, 1992; Sunderland et al., 2013). Therefore, it would be insufficient to only include patients without comorbid disorders, because that would be an unrepresentative selection of all patients with health anxiety. Finally, the quality of both treatments was high (i.e., specific training for the therapists, regular supervision by experts, and existence of a detailed treatment manual), which led to a high level of treatment integrity. Therefore, the findings might not be generalizable to routine mental healthcare, because it can be expected that treatment standards are less high. Since the beginning of the current study in 2010, the DSM criteria for hypochondriasis have changed. In the DSM-5, hypochondriasis is divided into two disorders (American Psychiatric Association, 2013). On the one hand, somatic symptom disorder should be considered when one or more somatic symptoms are present, and on the other hand, illness anxiety disorder should be considered when somatic symptoms are not present. In the current study, patients with hypochondriasis had a PHQ-15 score of 8.2 (SD ⫽ 4.7), which is comparable to patients with an anxiety disorder (M ⫽ 9.7; SD ⫽ 5.8; Höfling & Weck, 2013) but lower than in patients with medically unexplained symptoms (M ⫽ 12.7; SD ⫽ 4.8; Konnopka et al., 2013). Therefore, in the current study, somatic symptoms are not of high relevance and findings can be seen as more relevant for illness anxiety disorder than for somatic symptom disorder. Moreover, the usefulness of splitting hypochondriasis into two diagnoses in the DSM-5 has been criticized and it has been questioned whether different therapeutic approaches for the different disorders are necessary (e.g., Rief, 2013; Rief & Martin, 2014). Therefore, future studies should show whether different approaches are useful for the treatment of patients (with health anxiety as their primary problem) with illness anxiety disorder and somatic symptom disorder. Furthermore, it can be questioned whether similar results would be found for persons with health anxiety who do not meet the diagnostic criteria for hypochondriasis. Empirical investigations have shown that persons with a high level of health anxiety and persons with the diagnosis of hypochondriasis were found to be comparable in several characteristics (e.g., level of disturbance, persistence of health anxiety, frequency of healthcare use; Fink et al., 2010). Moreover, differences between health anxiety and hypochondriasis are quantitative rather than qualitative (Ferguson, 2009; Longley et al., 2010). Therefore, it can be expected that comparable treatment results would emerge for persons with elevated health anxiety.

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Received August 6, 2014 Revision received October 9, 2014 Accepted October 26, 2014 䡲