Expert Review of Pharmacoeconomics & Outcomes Research
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierp20
Response to letter to the editor on ‘Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes’ Erland Axelsson & Erik Hedman-Lagerlöf To cite this article: Erland Axelsson & Erik Hedman-Lagerlöf (2020): Response to letter to the editor on ‘Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes’, Expert Review of Pharmacoeconomics & Outcomes Research, DOI: 10.1080/14737167.2020.1831240 To link to this article: https://doi.org/10.1080/14737167.2020.1831240
Published online: 10 Oct 2020.
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EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH https://doi.org/10.1080/14737167.2020.1831240
LETTER TO THE EDITOR
Response to letter to the editor on ‘Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes’ Erland Axelsson
a
and Erik Hedman-Lagerlöfa,b
a Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; bOsher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Dear Editor, Thank you for giving us the opportunity to respond to this letter concerning our recent meta-analysis of randomized con trolled trials of cognitive behavior therapy (CBT) for health anxiety [1]. While we agree with some points raised, we object to others. For sake of simplicity, we will address the issues raised in a point-by-point fashion. We agree with the following issues raised by the author of the letter to the editor: 1. It is true that this systematic review was not preregis tered, and we agree that this is a threat to validity. For context, the study was originally intended only for inclusion in the introduction of a doctoral dissertation. 2. It is also true that, rather unsurprisingly, had we not included waitlist–controlled trials, the overall pooled con trolled effect size had been substantially smaller. This should be clear from the original publication (Figure 2, Table 3), where we reported that the choice of control condition was a significant moderator of the overall pooled effect, and tabu lated separate pooled effects of CBT versus other psychologi cal treatments, treatment-as-usual conditions, and waiting-list conditions, respectively. Our decision to nevertheless pool all available controlled effects, including those versus waitinglists, in the primary analysis was primarily an attempt to harmonize our study with previous meta-analyses of CBT for health anxiety which used the same method [2,3]. 3. We agree that, in hindsight, it had been good practice to comment further on the fact that CBT was not significantly more effective than antidepressants or pill placebo in the two trials that used these controls. The authors of one of those trials commented on the relatively weak effect of CBT and mentioned a few possible explanations, such as poor treat ment retention and that a relatively short 6-session CBT was used [4]. Direct comparisons between active treatments are so far few, but it may well prove that several treatments do as well as CBT in the treatment of health anxiety. That said, as of today, CBT is by far the most empirically supported treatment for health anxiety. 4. Contrary to what the author of the letter to the editor appears to insinuate, we agree that there was high hetero geneity and it is simply not true that control group being
CONTACT Erland Axelsson Sweden
[email protected]
© 2020 Informa UK Limited, trading as Taylor & Francis Group
a significant moderator ‘was not commented on further in the paper.’ Rather, similar to the author of the letter, we pointed out that there was ‘substantial heterogeneity in sev eral of our analyses. As judged from our moderator analyses, this is probably to some extent accounted for by the use of different control groups. As shown in Table 3, the heteroge neity was small to moderate (44%) in pooled comparisons to wait-list controls, but large when comparing CBT to other psychological treatments (84%)’ (p. 673). We disagree with the following issues raised by the author of the letter to the editor: 5. The author appears to suggest that we focused on sub clinical problems. This is incorrect. Rather, clinical trials were included only if participants had clinically significant symp toms (p. 664) and a majority of included trials (11 out of 19) used a diagnosis of hypochondriasis as inclusion criterion. Also, as shown in Table 3, whether inclusion was based on a diagnosis or cutoff on an established health anxiety measure did not moderate the outcome, and heterogeneity was about as large regardless. 6. We believe that we had good reasons to include clinical trials with recruitment based on DSM-5 somatic symptom disorder. To see why, it is first necessary to understand that, contrary to what was stated in the letter, hypochondriasis was not ‘termed illness anxiety disorder’ in the DSM-5. Rather, the entire DSM-IV chapter on somatoform disorders was reworked in such a way that no single disorder of the DSM-5 corre sponds to DSM-IV hypochondriasis in a 1:1 fashion [5]. A substantial portion, probably the majority, of those who met criteria for DSM-IV hypochondriasis are now believed to meet the criteria for somatic symptom disorder rather than illness anxiety disorder [6]. Thus, had we only included patients with illness anxiety disorder in studies published after the advent of the DSM-5 in 2013, we had probably excluded more than half of patients who had hypothetically met criteria for hypochondriasis. While it is true that somatic symptom disorder is a broad diagnosis intended to capture most somatoform disorders of the DSM-IV including somatization disorder and pain disorder [5], we included clinical trials of somatic symptom disorder
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 65,
2
E. AXELSSON AND E. HEDMAN-LAGERLÖF
only ‘under the condition that recruitment clearly focused on those who were significantly worried about their health and feared having or developing a severe illness’ (p. 664) which implies that patients were likely to have qualified for diagnosis of hypochondriasis under the DSM-IV. Corroborating that the overlap was substantial, clinical trials based on the DSM-5 also assessed DSM-IV hypochondriasis in parallel and found it to have a prevalence of 50%, 89%, and 99%, respectively, [7–9]. To the extent that patients did not meet full criteria for hypochondriasis, this was probably not a question of somatic symptom disorder being a less severe condition. Rather, illus tratively, in a recent trial based on the DSM-5 [10], we found that the most common reason for not having hypochondriasis was not having been given medical reassurance, which was often due to phobic avoidance of health care. At least in our data (N = 303, 13 measurement points) [8,10], whether patients recruited according to the DSM-5 met full criteria for hypochondriasis also did not appear to predict withingroup improvement in CBT (p =.982). In summary, if patients are recruited to take part in treatment for health anxiety, somatic symptom disorder is likely to represent clinically sig nificant health anxiety. 7. We were unjustly accused of having cherry-picked our outcomes. According to the letter, ‘[our] methodology appears to prioritize outcomes measured on the Short Health Anxiety Inventory (SHAI) over those derived on Whiteley Index (WI). However, it can be seen that the authors were inconsistent on this point and in some studies where both the SHAI and Whitely were available [9,11,12] they chose differently and used the scale that reported the larger CBT-related improve ment.’ This has a simple explanation. As we stated in the methods (‘Data extraction’, p. 665), we went by the straight forward rule of tabulating ‘the primary [health anxiety] out come of [each] trial, usually a self-rated questionnaire. In cases where no primary outcome was defined, we chose the first reported health anxiety outcome with two exceptions. In one case [13], we chose a visual-analogue scale (“time spent wor ried about health”) based on its acceptable construct validity, and that it was similar to the only other visual-analogue scale included in the review [14]. In the other case [15], the primary outcome was a clinician-rated measure, and in order to facil itate comparisons over studies we instead tabulated a selfrated (secondary) measure of health anxiety.’ Thus, the simple reason why the Whiteley Index was tabulated rather than the Health Anxiety Inventory in the three cited trials [9,11,12] was that the former was presented as the primary outcome. The practice of tabulating the primary outcome from each trial has been used in at least one previous meta-analysis of CBT for health anxiety [2], and is common in meta-analyses of clinical trials in general. Further illustrating the fact that we did not pick and choose our outcomes, contrary to what was insinuated in the letter, it appears to us that the controlled effect had been larger (not smaller) if based on the 14-item Health Anxiety Inventory in one of the three cited trials (Table 2 on p. 159 in that publica tion) [9]. There are also at least two additional examples where larger effects were seen on secondary health anxiety out comes that we did not report because these were judged as secondary [8,16].
8. We fail to see how our meta-analysis is likely to lead to the underpowering of future clinical trials. Presumably, at least for conventional superiority trials, power analyses ought to be based on prior knowledge about the comparison of primary interest. That is, a wait-list–controlled clinical trial would for example have to be powered based on evidence and assump tions pertaining to comparisons versus waiting-lists specifi cally. We did provide such estimates whenever possible (Table 3). It would make little sense for most investigators to base their power analysis on the overall pooled effect size (a mixture of controls), regardless of whether waitlist-controls were included or not. In summary, we found some of this critique relevant, and other aspects less so. We concede that we could have com mented further on the lack of preregistration, and perhaps also on individual studies that compared CBT to antidepres sants or pill placebo. However, we object to the critique of our eligibility criteria and tabulation of outcomes. Also, as con trolled effects vs treatment as usual and other psychological interventions were moderate in size, two out of three patients appeared to respond to treatment, and effects were sustained over time, we maintain that CBT appears to be highly effective for sufferers of health anxiety. That said, it is probably possible to improve this treamtent further. Sincerely, Erland Axelsson and Erik Hedman-Lagerlöf
Declaration of interests The authors have written books about CBT for health anxiety for which they receive royalties. EA gives lectures on CBT for health anxiety for which he receives payment.
ORCID Erland Axelsson
http://orcid.org/0000-0003-2562-2925
References 1. Axelsson E, Hedman-Lagerlöf E. Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes. Expert Rev Pharmacoecon Outcomes Res. 2019;19(6):663–676. 2. Olatunji BO, Kauffman BY, Meltzer S, et al. Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators. Behav Res Ther. 2014;58:65–74. 3. Cooper K, Gregory JD, Walker I, et al. Cognitive behaviour therapy for health anxiety: a systematic review and meta-analysis. Behav Cogn Psychother. 2017;45(2):110–123. 4. Fallon BA, Ahern DK, Pavlicova M, et al. Trial of medication and cognitive-behavioral therapy for hypochondriasis. Am J Psychiatry. 2017;174(8):756–764. 5. Dimsdale JE, Creed F, Escobar J, et al. Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013;75(3):223–228. 6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013. 7. Newby JM, Hobbs MJ, Mahoney AEJ, et al. DSM-5 illness anxiety disorder and somatic symptom disorder: comorbidity, correlates, and overlap with DSM-IV hypochondriasis. J Psychosom Res. 2017;101:31–37.
EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH
8. Hedman E, Axelsson E, Andersson E, et al. Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: rando mised controlled trial. Br J Psychiatry. 2016;209(5):407–413. 9. Skjernov M. Group cognitive behaviour therapy for severe health anxiety: A randomised controlled trial: University of Copenhagen; 2017. 10. Axelsson E, Andersson E, Ljótsson B, et al. Effect of internet vs face-to-face cognitive behavior therapy for health anxiety: a randomized noninferiority clinical trial. JAMA Psychiatry. 2020;77(9):915. 11. Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochon driasis: a randomized controlled trial. JAMA. 2004;291 (12):1464–1470. 12. Bourgault-Fagnou MD, Hadjistavropoulos HD. A randomized trial of two forms of cognitive behaviour therapy for an older adult
13.
14.
15.
16.
3
population with subclinical health anxiety. Cogn Behav Ther. 2013;42(1):31–44. Warwick HM, Clark DM, Cobb AM, et al. A controlled trial of cognitive-behavioural treatment of hypochondriasis. Br J Psychiatry. 1996;169(2):189–195. Clark DM, Salkovskis PM, Hackmann A, et al. Two psychological treatments for hypochondriasis: a randomised controlled trial. Br J Psychiatry. 1998;173:218–225. Weck F, Neng JM, Richtberg S, et al. Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): a randomized controlled trial. J Consult Clin Psychol. 2015;83 (4):665–676. Hedman E, Axelsson E, Görling A, et al. Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: randomised con trolled trial. Br J Psychiatry. 2014;205(4):307–314.
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierp20
Response to letter to the editor on ‘Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes’ Erland Axelsson & Erik Hedman-Lagerlöf To cite this article: Erland Axelsson & Erik Hedman-Lagerlöf (2020): Response to letter to the editor on ‘Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes’, Expert Review of Pharmacoeconomics & Outcomes Research, DOI: 10.1080/14737167.2020.1831240 To link to this article: https://doi.org/10.1080/14737167.2020.1831240
Published online: 10 Oct 2020.
Submit your article to this journal
Article views: 8
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ierp20
EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH https://doi.org/10.1080/14737167.2020.1831240
LETTER TO THE EDITOR
Response to letter to the editor on ‘Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes’ Erland Axelsson
a
and Erik Hedman-Lagerlöfa,b
a Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; bOsher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Dear Editor, Thank you for giving us the opportunity to respond to this letter concerning our recent meta-analysis of randomized con trolled trials of cognitive behavior therapy (CBT) for health anxiety [1]. While we agree with some points raised, we object to others. For sake of simplicity, we will address the issues raised in a point-by-point fashion. We agree with the following issues raised by the author of the letter to the editor: 1. It is true that this systematic review was not preregis tered, and we agree that this is a threat to validity. For context, the study was originally intended only for inclusion in the introduction of a doctoral dissertation. 2. It is also true that, rather unsurprisingly, had we not included waitlist–controlled trials, the overall pooled con trolled effect size had been substantially smaller. This should be clear from the original publication (Figure 2, Table 3), where we reported that the choice of control condition was a significant moderator of the overall pooled effect, and tabu lated separate pooled effects of CBT versus other psychologi cal treatments, treatment-as-usual conditions, and waiting-list conditions, respectively. Our decision to nevertheless pool all available controlled effects, including those versus waitinglists, in the primary analysis was primarily an attempt to harmonize our study with previous meta-analyses of CBT for health anxiety which used the same method [2,3]. 3. We agree that, in hindsight, it had been good practice to comment further on the fact that CBT was not significantly more effective than antidepressants or pill placebo in the two trials that used these controls. The authors of one of those trials commented on the relatively weak effect of CBT and mentioned a few possible explanations, such as poor treat ment retention and that a relatively short 6-session CBT was used [4]. Direct comparisons between active treatments are so far few, but it may well prove that several treatments do as well as CBT in the treatment of health anxiety. That said, as of today, CBT is by far the most empirically supported treatment for health anxiety. 4. Contrary to what the author of the letter to the editor appears to insinuate, we agree that there was high hetero geneity and it is simply not true that control group being
CONTACT Erland Axelsson Sweden
[email protected]
© 2020 Informa UK Limited, trading as Taylor & Francis Group
a significant moderator ‘was not commented on further in the paper.’ Rather, similar to the author of the letter, we pointed out that there was ‘substantial heterogeneity in sev eral of our analyses. As judged from our moderator analyses, this is probably to some extent accounted for by the use of different control groups. As shown in Table 3, the heteroge neity was small to moderate (44%) in pooled comparisons to wait-list controls, but large when comparing CBT to other psychological treatments (84%)’ (p. 673). We disagree with the following issues raised by the author of the letter to the editor: 5. The author appears to suggest that we focused on sub clinical problems. This is incorrect. Rather, clinical trials were included only if participants had clinically significant symp toms (p. 664) and a majority of included trials (11 out of 19) used a diagnosis of hypochondriasis as inclusion criterion. Also, as shown in Table 3, whether inclusion was based on a diagnosis or cutoff on an established health anxiety measure did not moderate the outcome, and heterogeneity was about as large regardless. 6. We believe that we had good reasons to include clinical trials with recruitment based on DSM-5 somatic symptom disorder. To see why, it is first necessary to understand that, contrary to what was stated in the letter, hypochondriasis was not ‘termed illness anxiety disorder’ in the DSM-5. Rather, the entire DSM-IV chapter on somatoform disorders was reworked in such a way that no single disorder of the DSM-5 corre sponds to DSM-IV hypochondriasis in a 1:1 fashion [5]. A substantial portion, probably the majority, of those who met criteria for DSM-IV hypochondriasis are now believed to meet the criteria for somatic symptom disorder rather than illness anxiety disorder [6]. Thus, had we only included patients with illness anxiety disorder in studies published after the advent of the DSM-5 in 2013, we had probably excluded more than half of patients who had hypothetically met criteria for hypochondriasis. While it is true that somatic symptom disorder is a broad diagnosis intended to capture most somatoform disorders of the DSM-IV including somatization disorder and pain disorder [5], we included clinical trials of somatic symptom disorder
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 65,
2
E. AXELSSON AND E. HEDMAN-LAGERLÖF
only ‘under the condition that recruitment clearly focused on those who were significantly worried about their health and feared having or developing a severe illness’ (p. 664) which implies that patients were likely to have qualified for diagnosis of hypochondriasis under the DSM-IV. Corroborating that the overlap was substantial, clinical trials based on the DSM-5 also assessed DSM-IV hypochondriasis in parallel and found it to have a prevalence of 50%, 89%, and 99%, respectively, [7–9]. To the extent that patients did not meet full criteria for hypochondriasis, this was probably not a question of somatic symptom disorder being a less severe condition. Rather, illus tratively, in a recent trial based on the DSM-5 [10], we found that the most common reason for not having hypochondriasis was not having been given medical reassurance, which was often due to phobic avoidance of health care. At least in our data (N = 303, 13 measurement points) [8,10], whether patients recruited according to the DSM-5 met full criteria for hypochondriasis also did not appear to predict withingroup improvement in CBT (p =.982). In summary, if patients are recruited to take part in treatment for health anxiety, somatic symptom disorder is likely to represent clinically sig nificant health anxiety. 7. We were unjustly accused of having cherry-picked our outcomes. According to the letter, ‘[our] methodology appears to prioritize outcomes measured on the Short Health Anxiety Inventory (SHAI) over those derived on Whiteley Index (WI). However, it can be seen that the authors were inconsistent on this point and in some studies where both the SHAI and Whitely were available [9,11,12] they chose differently and used the scale that reported the larger CBT-related improve ment.’ This has a simple explanation. As we stated in the methods (‘Data extraction’, p. 665), we went by the straight forward rule of tabulating ‘the primary [health anxiety] out come of [each] trial, usually a self-rated questionnaire. In cases where no primary outcome was defined, we chose the first reported health anxiety outcome with two exceptions. In one case [13], we chose a visual-analogue scale (“time spent wor ried about health”) based on its acceptable construct validity, and that it was similar to the only other visual-analogue scale included in the review [14]. In the other case [15], the primary outcome was a clinician-rated measure, and in order to facil itate comparisons over studies we instead tabulated a selfrated (secondary) measure of health anxiety.’ Thus, the simple reason why the Whiteley Index was tabulated rather than the Health Anxiety Inventory in the three cited trials [9,11,12] was that the former was presented as the primary outcome. The practice of tabulating the primary outcome from each trial has been used in at least one previous meta-analysis of CBT for health anxiety [2], and is common in meta-analyses of clinical trials in general. Further illustrating the fact that we did not pick and choose our outcomes, contrary to what was insinuated in the letter, it appears to us that the controlled effect had been larger (not smaller) if based on the 14-item Health Anxiety Inventory in one of the three cited trials (Table 2 on p. 159 in that publica tion) [9]. There are also at least two additional examples where larger effects were seen on secondary health anxiety out comes that we did not report because these were judged as secondary [8,16].
8. We fail to see how our meta-analysis is likely to lead to the underpowering of future clinical trials. Presumably, at least for conventional superiority trials, power analyses ought to be based on prior knowledge about the comparison of primary interest. That is, a wait-list–controlled clinical trial would for example have to be powered based on evidence and assump tions pertaining to comparisons versus waiting-lists specifi cally. We did provide such estimates whenever possible (Table 3). It would make little sense for most investigators to base their power analysis on the overall pooled effect size (a mixture of controls), regardless of whether waitlist-controls were included or not. In summary, we found some of this critique relevant, and other aspects less so. We concede that we could have com mented further on the lack of preregistration, and perhaps also on individual studies that compared CBT to antidepres sants or pill placebo. However, we object to the critique of our eligibility criteria and tabulation of outcomes. Also, as con trolled effects vs treatment as usual and other psychological interventions were moderate in size, two out of three patients appeared to respond to treatment, and effects were sustained over time, we maintain that CBT appears to be highly effective for sufferers of health anxiety. That said, it is probably possible to improve this treamtent further. Sincerely, Erland Axelsson and Erik Hedman-Lagerlöf
Declaration of interests The authors have written books about CBT for health anxiety for which they receive royalties. EA gives lectures on CBT for health anxiety for which he receives payment.
ORCID Erland Axelsson
http://orcid.org/0000-0003-2562-2925
References 1. Axelsson E, Hedman-Lagerlöf E. Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes. Expert Rev Pharmacoecon Outcomes Res. 2019;19(6):663–676. 2. Olatunji BO, Kauffman BY, Meltzer S, et al. Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators. Behav Res Ther. 2014;58:65–74. 3. Cooper K, Gregory JD, Walker I, et al. Cognitive behaviour therapy for health anxiety: a systematic review and meta-analysis. Behav Cogn Psychother. 2017;45(2):110–123. 4. Fallon BA, Ahern DK, Pavlicova M, et al. Trial of medication and cognitive-behavioral therapy for hypochondriasis. Am J Psychiatry. 2017;174(8):756–764. 5. Dimsdale JE, Creed F, Escobar J, et al. Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013;75(3):223–228. 6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013. 7. Newby JM, Hobbs MJ, Mahoney AEJ, et al. DSM-5 illness anxiety disorder and somatic symptom disorder: comorbidity, correlates, and overlap with DSM-IV hypochondriasis. J Psychosom Res. 2017;101:31–37.
EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH
8. Hedman E, Axelsson E, Andersson E, et al. Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: rando mised controlled trial. Br J Psychiatry. 2016;209(5):407–413. 9. Skjernov M. Group cognitive behaviour therapy for severe health anxiety: A randomised controlled trial: University of Copenhagen; 2017. 10. Axelsson E, Andersson E, Ljótsson B, et al. Effect of internet vs face-to-face cognitive behavior therapy for health anxiety: a randomized noninferiority clinical trial. JAMA Psychiatry. 2020;77(9):915. 11. Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochon driasis: a randomized controlled trial. JAMA. 2004;291 (12):1464–1470. 12. Bourgault-Fagnou MD, Hadjistavropoulos HD. A randomized trial of two forms of cognitive behaviour therapy for an older adult
13.
14.
15.
16.
3
population with subclinical health anxiety. Cogn Behav Ther. 2013;42(1):31–44. Warwick HM, Clark DM, Cobb AM, et al. A controlled trial of cognitive-behavioural treatment of hypochondriasis. Br J Psychiatry. 1996;169(2):189–195. Clark DM, Salkovskis PM, Hackmann A, et al. Two psychological treatments for hypochondriasis: a randomised controlled trial. Br J Psychiatry. 1998;173:218–225. Weck F, Neng JM, Richtberg S, et al. Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): a randomized controlled trial. J Consult Clin Psychol. 2015;83 (4):665–676. Hedman E, Axelsson E, Görling A, et al. Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: randomised con trolled trial. Br J Psychiatry. 2014;205(4):307–314.
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