ICBT for Severe Health Anxiety

Module

Exposure-based CBT

Main homework assignments

Introduction to CBT and mindfulness exercise

Mindfulness training, health anxiety behaviour diary

Presentation of the CBT model, continued mindfulness training

Mindfulness training, completion of idiosyncratic health anxiety model, health anxiety behaviour diary

Cognitive processes, continued mindfulness training

Work relating to cognitive processes, mindfulness training, health anxiety behaviour diary

Interoceptive exposure, continued mindfulness training

Exposure exercises

Response prevention, continued mindfulness training

Exposure exercises

Exposure to health anxiety-provoking stimuli

Exposure exercises

Exposure to illness thoughts

Exposure exercises

Continued exposure and response prevention

Exposure exercises

Continued exposure and response prevention

Exposure exercises

Continued exposure and response prevention

Exposure exercises

A summary of the treatment

Exposure exercises, writing a summary of the treatment focusing on most helpful interventions

Maintaining gains and relapse prevention

Exposure exercises, writing a plan on how to continue improving and how to prevent and handle relapse

Starting in the early phase of treatment, mindfulness training is used as a means to enhance exposure. This means that mindfulness is not used as a stand-alone intervention but as a way to increase the probability that clients conduct often highly anxiety-provoking exposure exercises and that they will not use distraction as a means to cope with worrying sensations. The treatment therefore differs from the mindfulness-based cognitive therapy of McManus and co-workers (McManus et al. 2012) where mindfulness is used as the main intervention of the treatment. In our treatment, the training in mindfulness comprises daily exercises in directing attention to different stimuli including the body while observing thoughts and emotions without trying to change them. During later stages of the treatment when exposure is introduced, the client is encouraged to use skills in mindfulness to increase tolerance for aversive internal reactions. Although it is not exactly clear how mindfulness achieves it effects, it has been suggested that it could facilitate extinction learning during exposure through increasing awareness of multiple conditioned triggers of anxiety (Treanor 2011). The general stance that clients are encouraged to accept aversive thoughts and feelings when conducting exposure and using mindfulness means that the treatment to some extent uses elements of third-wave CBT but within an exposure-extinction paradigm. As described in Table 9.1, the treatment, besides exposure and mindfulness training, also entails psychoeducation about CBT and severe health anxiety, and relapse prevention.

When it comes to the treatment structure, it is similar to the many of the Swedish ICBT treatments for other disorders in the sense that it to a large extent is built upon extensive self-help texts with relatively few advanced technical features. Integrated in the treatment platform where the client accesses the treatment are also worksheets, a system for symptom assessment and a secure messaging function. The contact between the therapist and client is almost exclusively in form of text messages and therapists generally spend about 10 min weekly per patient making it a minimal therapist contact treatment.

Studies on Internet-Based CBT for Severe Health Anxiety

Efficacy and Long-Term Outcomes

The protocol underlying the so far only published Internet-based treatment for severe health anxiety was first tested in an open clinical trial using a conventional face-to-face delivery format and was found to be effective in reducing health anxiety, as well as general anxiety and depressive symptoms (Hedman et al. 2010). Thereafter, the treatment was adopted for being delivered as an Internet-based treatment and has of today been tested in two randomised controlled trials for clients with severe health anxiety. In the first trial (N = 81), the treatment was compared to a basic attention control condition that did not receive active treatment (Hedman et al. 2011). The results showed that ICBT yielded large effects on the primary outcome of health anxiety (Health Anxiety Inventory; HAI) with a between-group d of 1.62 at post-treatment. The treatment also produced large within-group improvements on the same measure (pre to post d = 1.94; pre to 6-month follow-up d = 2.09) and on measures of general anxiety, depressive symptoms and anxiety sensitivity (pre to post d range = 0.90–1.19). At 6-month follow-up, 80 % of participants who had received ICBT no longer met diagnostic criteria for severe health anxiety (Hedman et al. 2011).

One main limitation of this trial was that the control group did not receive active treatment. In a subsequent trial (N = 158), we therefore pitted the treatment against behavioural stress management comprising mainly applied relaxation and interventions aimed at reducing stress (Hedman et al. 2014). This was considered a tough test not least because applied relaxation has been found to be effective in the treatment for both panic disorder and generalised anxiety disorder. Assessments of treatment credibility and working alliance showed that the two treatments were equal in these regards. In line with prediction, exposure-based ICBT was found to yield significantly larger improvements on the primary outcome compared to behavioural stress management. Within-group improvements in ICBT were large on the primary outcome HAI (pre to post d = 1.78), but as participants receiving behavioural stress management also made substantial improvements, the between-group effect size at post-treatment was clearly smaller than in the previous RCT (d = 0.26). The findings can be viewed as important as they show that systematic exposure causes improvements above and beyond those that can be achieved through taking part of a credible and active psychological treatment entailing systematic behaviour change (Hedman et al. 2014).

As for long-term effects, a recently published study showed that ICBT for severe health anxiety can lead to improvements that are sustained for at least one year post-treatment (Hedman et al. 2013a). The effect size (pre to 1-year follow-up) on the primary outcome HAI was d = 1.95 which is largely the same as the pre to post d of 1.94. The same stability of improvements was found on measures of general anxiety, depressive symptoms and anxiety sensitivity (Hedman et al. 2013a). It thus seems as ICBT for severe health anxiety can lead to large improvements that are long-term enduring.

Predictors and Mediators

Although ICBT is effective, not all clients respond sufficiently to treatment and it is therefore of importance to investigate predictors of improvement, which could facilitate the clinician in making treatment decisions. In a predictor study, based on the first RCT described above, we found that more health anxiety at baseline predicted more anxiety at 6-month follow-up but also larger improvements thus indicating that ICBT is a suitable treatment also for clients with more severe symptoms (Hedman et al. 2013b). Depressive symptoms were however found to be a negative predictor in the sense that more depressive symptoms at baseline predicted less improvement of health anxiety. This means that it could be clinically important that clients with comorbid depression are carefully monitored during the treatment so that signs of nonresponding could be dealt with early and additional treatment options discussed (e.g. structured therapist support via telephone). Interesting findings of the study were also that demographic characteristics and computer skills seemed to be largely unrelated to outcome meaning that ICBT suits equally well for old and young, men and women and highly computer skilled or not. When it comes to therapy process-related variables, the only one having a significant impact on outcome was treatment adherence operationalised as number of completed modules (Hedman et al. 2013b). In line with predictor research from other domains, this indicates that it is important that the client actually engages in the exposure exercises throughout the treatment.

When it comes to mediators, only one study has so far been published on ICBT for severe health anxiety (Hedman et al. 2013c). In that study, we investigated putative mechanisms and found that intolerance of uncertainty, reduced attention to bodily symptoms and reduced perceived risk of disease mediated subsequent improvement in health anxiety. The findings support a cognitive behavioural model of severe health anxiety and are interesting as they show that a treatment highly focused on exposure and response prevention produces significant effect on these largely cognitive mediators, which in turn are related to outcome. An interesting venue for future research in this domain is to investigate the potential role of reduced avoidance as a mechanism of change.

Case Description

Cathy, 39, has always been more anxious than others, but in the last few years, especially since her uncle died in cancer, her worry regarding her health has become close to impossible to handle. She fears two things more than anything else—cancer and ALS. Since at least a year, Cathy easily gets caught up in different bodily sensations that could be a sign of either of these two terrible diseases. Lately, her worry has become a really big problem as it is on her mind nearly all the time. When worried, she finds it difficult to concentrate at work and it has also become a large problem in the relationship with her husband Steve as she often wants to talk about her potential symptoms and get reassurance. Sometimes, she needs to call Steve at work several times a day to be fully convinced that she is not sick. From different health sites on the Internet, she has learned that feelings of dizziness and feeling weak might be early symptoms of ALS, which has led to two things. First, she is constantly scanning her body for these potential disease symptoms, and she does it so much that it has practically become an automatic behaviour that she does not initiate deliberately. Second, when she discovers a worrying sensation, such as a feeling that she is a bit unsteady, she instantly looks it up on Google. Although she at this stage is not overly worried, it almost always ends up with her being extremely fearful as the following occurs: she performs searches on her present symptom and the feared diseases, e.g. “dizziness AND ALS”. Starting with relatively credible health-care sites, she finds that dizziness indeed might be a symptom of ALS, although dizziness also is common for other reasons. Cathy gets a little bit more worried and scrutinises the entire list of symptoms common in ALS patients and finds that headache and having and trouble remembering things could also be part of the early symptom presentation. Now, Cathy starts getting really worried as she has had headache almost every day the past week and she sometimes feels that she forgets thing a bit too often at work. So, she now knows that she has at least three of potential symptoms and continues googling about ALS and becomes almost terrified when she finds blogs written by people with ALS who document their lives. Reading about the certain deterioration and losing control of one’s body is just too much. Cathy is at this time point convinced that she actually has ALS and starts crying and reaches for the telephone to schedule an appointment with her GP. To her great luck, she gets the opportunity to talk to her GP directly on the phone and he convinces her that her bodily sensations are perfectly normal and no signs of ALS. Cathy feels very relieved and for a while almost a bit shameful for jumping to conclusions so rapidly. A few hours later, she however comes to think of a case she heard where the doctor said everything was alright but where it turned out that the patient had a severe form of cancer. As Cathy’s doctor didn’t even perform any kind of examination but just talked to her on the phone, how could he really know that it is not ALS? And the worry is back…

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