Cognitive-Behavioural Bibliotherapy for Hypochondriasis

The present study aims to determine whether cognitive behavioural minimalcontact bibliotherapy is acceptable to participants suffering from DSM-IV-TR hypochondriasis, and whether this intervention is able to reduce hypochondriacal complaints, as well as comorbid depressive complaints and trait anxiety. Participants (N = 40, 7 of whom dropped out), were randomised into either an immediate treatment condition or a waiting list condition. The waiting list period consisted of six weeks, as did the experimental period. Participants were sent a book called ‘Doctor, I hope it’s nothing serious? ’, containing cognitive behavioural theory and exercises. Measures of hypochondriacal complaints, depressive complaints, and trait anxiety, were taken pre, post and at follow-up (after 3 months). Those in the waiting list group received a second preassessment after 6 weeks, and were then enrolled in the bibliotherapy. Results showed that participants were accepting of the cognitive-behavioural theory described in the book, and found both the theory and exercises very useful, but generally performed the exercises only once. Furthermore, results showed beneficial effects of the intervention: all effect measures decreased significantly over time, with the largest effect at post-assessment. It is concluded that bibliotherapy can be an efficient aid in reducing hypochondriacal and comorbid complaints, preferably as part of a stepped care programme. Cognitive-Behavioural Bibliotherapy for Hypochondriasis / 107 Introduction Hypochondriacal patients suffer from the fear or conviction of having a serious physical disease, based on the misinterpretation of bodily symptoms (APA, 2000). Recent studies suggest the effectiveness of individual cognitivebehavioural interventions for this disorder (Barsky & Ahern, 2004; Visser & Bouman, 2001; Warwick, Clark, Cobb, & Salkovskis, 1996), and also of shortterm psychoeducational courses (Avia, Ruiz, Olivares, Crespo, Guisado, Sánchez, & Varela, 1996; Barsky, Geringer, & Wool, 1988; Bouman, 2002; Buwalda, Bouman, & Van Duijn, 2006). It has been hypothesised (Gould, Clum, & Shapiro, 1993) that the didactic and self-directed treatment strategies used in psychoeducation, could also very well be imparted by bibliotherapy. This is an intervention in which patients are being supplied with written self-help material, which they can work through independently, with minimal or no contact with a therapist. Bibliotherapy has become popular as a part of a stepped-care treatment program, in which it might be used as a first level of treatment before initiating more costly therapy (Fritzler, Hecker, & Losee, 1997). Advantages of this form of treatment are ease of use, cost-effectiveness, and the potential to provide services to people who are unwilling or unable to be engaged in a more traditional form of therapy (Cuijpers, 1997; Scogin, Hamblin, & Beutler, 1987; Williams, 2001), while it still can contain those non-specific elements in therapies that are thought to cause therapeutic effect, such as providing a clear rationale, a structured approach and training of skills (Zeiss, Lewinsohn, & Muñoz, 1979). Bibliotherapy can be administered in several ways: as a part of regular psychotherapy, as an independent form of intervention combined with a few sessions with a therapist, and as an independent intervention without therapy sessions. Many studies have centered on bibliotherapy as an independent treatment form, in which it has proven to be effective in the treatment of depression (Cuijpers, 1997; Floyd, Scogin, McKendree-Smith, Floyd, & Rokke, 2004; Gregory, Schwer Canning, Lee, & Wise, 2004; McKendree-Smith, Floyd, & Scogin, 2003; Scogin et al., 1987), sexual dysfunctioning (Van Lankveld, 1998), panic disorder and other anxiety disorders (Lidren, Watkins, Gould, Clum, Asterino, & Tulloch, 1994; Newman, Erickson, Przeworski, & Dzus, 2003; White, 1995; Wright, Clum, Roodman, & Febbraro, 2000), insomnia (Mimeault & Morin, 1999), and alcohol problems (Apodaca & Miller, 2003). Several meta-analyses have been undertaken, showing favourable effect sizes: Cuijpers (1997) reported a mean effect size of 0.82 for six studies that compared cognitive bibliotherapy participants, suffering from depression, with waiting list control participants. Gregory and others (2004) found an effect size of 0.77 for 17 between groups studies into bibliotherapy for depression, and state that this effect size compares favourably with data from studies of individual therapies. In a meta analysis reviewing bibliotherapy for a large variety of problems, Marrs (1995) analyzed 70 samples and found a mean effect size of 0.56. He states that bibliotherapy appeared more effective for certain problem types, such as assertion training, anxiety, and sexual dysfunctioning, than for others, such as weight loss, impulse control, and studying problems. Cognitive-Behavioural Bibliotherapy for Hypochondriasis / 108 Furthermore, he found that the extent of therapist contact during bibliotherapy did not seem to relate to effectiveness as a whole. Favourable effects of bibliotherapy have not only been found at posttreatment: maintained effects were reported at 8 years follow-up for alcohol problems (Apodaca et al., 2003), at 3 years follow-up for depression (Smith, Floyd, Scogin, & Jamison, 1997), and at 3 and 6 months follow-up for panic disorder (Lidren et al., 1994). These beneficial effects are comparable to therapist delivered interventions (Cuijpers, 1997; Gould & Clum, 1993). In their state-of-the-art review of treatments known to have been used for hypochondriasis, Taylor and Asmundson (2004) state that hypochondriasis, or health anxiety, has never been treated with bibliotherapy. However, to the best of our knowledge, one study investigated bibliotherapy for health anxiety (Jones, 2002). A total of 40 participants, suffering from health anxiety, as identified by their GPs, was randomised into two conditions: one receiving cognitive bibliotherapy and the other not. Results of this study showed a significant reduction in health anxiety after they had received bibliotherapy (Cohen’s d = 1.12). This study did suffer from some methodological flaws. Firstly, half of the 40 participants described in this study suffered both from health anxiety, and from identifiable physical diseases, but it was not reported whether participants feared the disease they suffered from. Secondly, it was not stated clearly whether the participants could be diagnosed as suffering from hypochondriasis, they were only identified by their GPs as demonstrating a variety of symptoms of health anxiety. Furthermore, when viewing scores on the Health Anxiety Questionnaire, used in the study to measure health anxiety complaints, substantial differences emerged between the control group and the experimental group (the control group had a mean score of 56.3 at preassessment, whereas the experimental group had a mean score of 75.1). Nevertheless, the results provide us with a first indication that bibliotherapy might be beneficial for hypochondriacal complaints. The first aim of the present study is to find out whether cognitivebehavioural bibliotherapy is an acceptable treatment for people suffering from DSM-IV-TR hypochondriasis. We expect this question to be answered affirmatively, because the psychoeducational approach, be it in group format, has earlier shown to be acceptable to hypochondriacal participants, who were willing to see themselves as students rather than patients. A second aim is to find out whether cognitive-behavioural bibliotherapy is an effective treatment for hypochondriasis. This question is also expected to be answered affirmatively, because in the recent past, treatments that employed instruction and self-directed practice of coping strategies (i.e. several cognitivebehavioural approaches) seemed most efficacious in the treatment of several disorders (Gould et al., 1993).