Cognitive Behavior Therapy to Teach 'New Ways' of Thinking Shows Promise
How can patients be "cured" when they continue to believe they are seriously ill despite all medical reassurances and other evidence to the contrary? It's a question that has long stymied doctors who treat the one in 20 Americans with hypochondria.
Now, a possible answer: Cognitive behavior therapy, a popular type of therapy that emphasizes how thinking affects feelings, actions, and even physical symptoms -- and teaches patients new ways of thinking to change unwanted feelings and behaviors.
A new study shows that just six, 90-minute individual sessions of this therapy -- used for pain reduction and to treat depression, shyness, eating disorders, and other conditions -- helped improved symptoms in 102 hypochondrial patients.
What's more, that improvement continued in follow-up exams done six and 12 months later, Harvard researchers report in this week's Journal of the American Medical Association. Another group of 85 hypochondriacs not getting this therapy had no such improvement.
"If we're right, this therapy is effective because it aims at the basic problem -- the way these patients think about their symptoms," researcher Arthur J. Barsky, MD, tells WebMD. "They tend to think that anything that bothers them has a medical explanation, when it in fact, that is not always true. Lower back pain is a perfect example. It can be severe but don't always have a medical explanation."
Hypochondriacs are preoccupied with their physical health and have an unrealistic fear of serious disease that is not in proportion to the actual risk. While they actually feel "real" symptoms, they may assume it's life-threatening -- and continue this belief for at least six months after being "cleared" in a medical evaluation.
"When they stand up and have dizziness, as happens normally to people on occasion, they think they're having a stroke," says Barsky, director of psychiatric research at Brigham and Women's Hospital and a professor of psychiatry at Harvard Medical School. "What distinguishes hypochondrial patients from 'worried well' is that they are not reassured by doctors after they've done tests and determined they do not have a serious illness."
Hypochondria Not Well Understood
Barsky tells WebMD that the cause of hypochondria is not well understood, but may result from childhood events, such as when a parent gets sick or dies. "When they reach that age where their father died of heart disease, they feel pressure in their chest," he says.
Currently, others types of therapy and antidepressants are used to treat hypochondriacs. "Traditional psychotherapy doesn't seem to be effective," Barsky says. "Some preliminary studies suggest drugs might be helpful, but antidepressant use has not been rigorously studied yet."
But the ramifications of his study could be huge. It's estimated that 15% of all health costs is to evaluate people who feel physical symptoms but have no diagnosable medical illness, Barsky says. However, not all of these patients are hypochondriacs.
"What's interesting and valuable about Dr. Barsky's study is that he has found you can use a form of structured psychotherapy to change the way people think. By changing the way they think, it helps them to understand their symptoms in a different way, and not be as frightened by them," says Steven Locke, MD, another Harvard psychiatrist who has studied hypochondria treatment options. "When their fear and anxiety associated with symptoms subsides, the symptoms themselves tend to subside because the nervous system quiets down."
Locke was not involved in Barsky's study, but his own research shows the benefits of therapy on those with medically unexplainable symptoms. In one study, Locke found that symptoms -- along with levels of anxiety -- noticeably decreased in a group of hypochondrial patients who underwent six weeks of group therapy in a classroom setting. "What we used had elements of cognitive behavior therapy," he tells WebMD. "And it was clinically effective."
In another study, Locke says that patients who had medically unexplained symptoms but were not diagnosed hypochondriacs had saved an average of $1,000 in medical costs one year after undergoing this therapy.
Still, despite these promising results -- "significantly lower levels of hypochondriacal symptoms, beliefs, and attitudes and health-related anxiety" among patients getting cognitive behavior therapy -- an important question remains:
How to convince patients who believe they are physically sick to get a thinking adjustment?
"Clearly, that is one of the major problems," Barsky tells WebMD. "From a patient's viewpoint, their problem is medical, so any kind of psychological approach doesn't make sense to them." His advice: This cognitive behavior therapy needs to be "imbedded" in the primary care process, rather than be an external referral to a psychiatrist.
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