Psychological therapies

Warwick and Marks(75) successfully treated a series of hypochondriacal patients using behavioural techniques. They reported that exposure to illness cues and prevention of reassurance produced rapid improvement—most patients responded and half remained well 5 years later. The authors noted that reassurance-seeking was a prominent feature and that prevention of this anxiety-relieving ritual was important to the success of treatment. This involved teaching family members how not to respond to requests for reassurance and asking doctors to avoid repeated examinations and tests.

Warwick et al.(76) conducted a controlled trial randomizing 22 patients to 16 sessions of cognitive-behavioural therapy or a waiting list. Cognitive procedures included identifying misinterpretations of signs and symptoms, constructing more realistic interpretations, restructuring images, and modifying dysfunctional assumptions. Behavioural procedures included induction of innocuous symptoms by body-focusing, graded exposure to illness-related situations, and prevention of repeated body-checking and reassurance-seeking. Patients who received cognitive-behavioural therapy, experienced a 76 per cent reduction in symptoms compared with 5 per cent among controls.

Although this trial establishes the efficacy of cognitive-behavioural treatment, it is unclear how acceptable this may be to patients or how cost-effective it may be. However, Stern and Fernandez(77) have shown that group treatment is feasible. To improve acceptance, these authors referred to their intervention as a course in stress management and carried it out in a general practice setting.

A few studies have examined the results of psychotherapy. In one of these, Kellner(74> reported improvement in two-thirds of patients after an average of 10 sessions. The therapy included repeated physical examinations and reassurance, as well as the provision of accurate information and persuasion about the innocuous nature of symptoms. Since the study was uncontrolled, the importance of the techniques used remains unclear.

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