Skip to main content Accessibility help
×
Home

Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial

  • Ditte Hoffmann (a1), Charlotte Ulrikka Rask (a2) (a3), Erik Hedman-Lagerlöf (a4), Jens Søndergaard Jensen (a1) and Lisbeth Frostholm (a1)...

Abstract

Background

Health anxiety is common, disabling and costly due to patients’ extensive use of health care services. Internet-delivered treatment may overcome barriers of accessibility to specialized treatment. We aimed to evaluate the efficacy of internet-delivered acceptance and commitment therapy (iACT).

Methods

A randomized, controlled trial of iACT versus an internet-delivered discussion forum (iFORUM), performed in a Danish university hospital setting. Patients self-referred and underwent video-diagnostic assessment. Eligible patients (≥18 years) with health anxiety were randomized to 12 weeks of intervention. The randomization was blinded for the assessor. The primary outcome was between-group unadjusted mean differences in health anxiety symptoms measured by the Whiteley-7 Index (WI-7, range 0–100) from baseline to 6-month follow-up (6-MFU) using intention to treat and a linear mixed model. The study is registered at clinicaltrials.gov, number NCT02735434.

Results

A total of 151 patients self-referred, and 101 patients were randomized to iACT (n = 53) or iFORUM (n = 48). A mean difference in change over time of 19.0 points [95% confidence interval (CI) 10.8–27.2, p < 0.001] was shown on the WI-7, and a large standardized effect size of d = 0.80 (95% CI 0.38–1.23) at 6-MFU. The number needed to treat was 2.8 (95% CI 1.8–6.1, p < 0.001), and twice as many patients in iACT were no longer clinical cases (35% v. 16%; risk ratio 2.17, 95% CI 1.00–4.70, p = 0.050). Adverse events were few and insignificant.

Conclusions

iACT for health anxiety led to sustained effects at 6-MFU. The study contributes to the development of easily accessible treatment options and deserves wider application.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial
      Available formats
      ×

Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Author for correspondence: Ditte Hoffmann, E-mail: dittjese@rm.dk

References

Hide All
A-Tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 3036. doi:10.1159/000365764.
Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., & Sharpe, D. (2013). The short health anxiety inventory: A systematic review and meta-analysis. Journal of Anxiety Disorders, 27(1), 6878. doi:10.1016/j.janxdis.2012.10.009.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. doi: ISBN: 978-0-89042-554-1.
Axelsson, E., & Hedman-Lagerlof, E. (2019). Cognitive behavior therapy for health anxiety: Systematic review and meta-analysis of clinical efficacy and health economic outcomes. Expert Review of Pharmacoeconomics & Outcomes Research, 19(6), 663676. doi:10.1080/14737167.2019.1703182.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Zettle, R. D. (2011). Preliminary psychometric properties of the acceptance and action questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676688. doi:http://dx.doi.org/10.1016/j.beth.2011.03.007.
Brown, M., Glendenning, A., Hoon, A. E., & John, A. (2016). Effectiveness of web-delivered acceptance and commitment therapy in relation to mental health and well-being: A systematic review and meta-analysis. Journal of Medical Internet Research, 18(8), e221. doi:10.2196/jmir.6200.
Carlbring, P., Andersson, G., Cuijpers, P., Riper, H., & Hedman-Lagerlof, E. (2018). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: An updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47(1), 118. doi:10.1080/16506073.2017.1401115.
Christensen, K. S., Bech, P., Fink, P. (2010). Measuring mental health by questionnaires in primary care – unidimensionality, responsiveness and compliance. European Psychiatric Review, 3(1), 912.
Derogatis, L. R., & Cleary, P. A. (1977). Confirmation of the dimensional structure of the SCL-90: A study in construct validation. Journal of Clinical Psychology, 33(4), 981989. doi:http://dx.doi.org/10.1002/1097-4679(197710)33:4<981::AID-JCLP2270330412>3.0.CO;2-0.
Donkin, L., Christensen, H., Naismith, S. L., Neal, B., Hickie, I. B., & Glozier, N. (2011). A systematic review of the impact of adherence on the effectiveness of e-therapies. Journal of Medical Internet Research, 13(3), e52. doi:10.2196/jmir.1772.
Eilenberg, T., Fink, P., Jensen, J. S., Rief, W., & Frostholm, L. (2016). Acceptance and commitment group therapy (ACT-G) for health anxiety: A randomized controlled trial. Psychological Medicine, 46(1), 103115. doi:10.1017/S0033291715001579.
Eilenberg, T., Hoffmann, D., Jensen, J. S., & Frostholm, L. (2017). Intervening variables in group-based acceptance & commitment therapy for severe health anxiety. Behaviour Research and Therapy, 92, 2431. doi:S0005-7967(17)30016-5 [pii].
Fallon, B. A., Ahern, D. K., Pavlicova, M., Slavov, I., Skritskya, N., & Barsky, A. J. (2017). A randomized controlled trial of medication and cognitive-behavioral therapy for hypochondriasis. The American Journal of Psychiatry, 174(8), 756764. doi:10.1176/appi.ajp.2017.16020189.
Fink, P., Ewald, H., Jensen, J., Sorensen, L., Engberg, M., Holm, M., & Munk-Jorgensen, P. (1999). Screening for somatization and hypochondriasis in primary care and neurological in-patients: A seven-item scale for hypochondriasis and somatization. Journal of Psychosomatic Research, 46(3), 261273. doi:S0022399998000920 [pii].
Fink, P., Ornbol, E., & Christensen, K. S. (2010). The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS ONE, 5(3), e9873. doi:10.1371/journal.pone.0009873.
Fink, P., Ornbol, E., Toft, T., Sparle, K. C., Frostholm, L., & Olesen, F. (2004). A new, empirically established hypochondriasis diagnosis. The American Journal of Psychiatry, 161(9), 16801691. doi:10.1176/appi.ajp.161.9.1680.
Frostholm, L., & Rask, C. U. (2019). Third wave treatments for functional somatic syndromes and health anxiety across the age span: A narrative review. Clinical Psychology in Europe, 1(1), 133. doi:10.32872/cpe.v1i1.32217.
Hayes, S. C. (2016). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies – republished article. Behavior Therapy, 47(6), 869885. doi:S0005-7894(16)30094-6 [pii].
Hedman, E., Andersson, G., Andersson, E., Ljotsson, B., Ruck, C., Asmundson, G. J., & Lindefors, N. (2011). Internet-based cognitive-behavioural therapy for severe health anxiety: Randomised controlled trial. The British Journal of Psychiatry: The Journal of Mental Science, 198(3), 230236. doi:10.1192/bjp.bp.110.086843.
Hedman, E., Andersson, E., Lindefors, N., Andersson, G., Ruck, C., & Ljotsson, B. (2013). Cost-effectiveness and long-term effectiveness of internet-based cognitive behaviour therapy for severe health anxiety. Psychological Medicine, 43(2), 363374. doi:10.1017/S0033291712001079.
Hedman, E., Axelsson, E., Andersson, E., Lekander, M., & Ljotsson, B. (2016). Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: Randomised controlled trial. The British Journal of Psychiatry: The Journal of Mental Science, 209(5), 407413. doi:bjp.bp.116.181396 [pii].
Hedman, E., Axelsson, E., Gorling, A., Ritzman, C., Ronnheden, M., El Alaoui, S., … Ljotsson, B. (2014). Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: Randomised controlled trial. The British Journal of Psychiatry : The Journal of Mental Science, 205(4), 307314. doi:10.1192/bjp.bp.113.140913.
Hoffmann, D., Rask, C. U., Hedman-Lagerlof, E., Eilenberg, T., & Frostholm, L. (2019). Accuracy of self-referral in health anxiety: Comparison of patients self-referring to internet-delivered treatment versus patients clinician-referred to face-to-face treatment. BJPsych Open, 5(5), e80. doi:10.1192/bjo.2019.54.
Hoffmann, D., Rask, C. U., Hedman-Lagerlof, E., Ljótsson, B., & Frostholm, L. (2018). Development and feasibility testing of internet-delivered acceptance and commitment therapy for severe health anxiety: Pilot study. JMIR Mental Health, 5(2), e28. doi:10.2196/mental.9198.
Holmes, E. A., Ghaderi, A., Harmer, C. J., Ramchandani, P. G., Cuijpers, P., Morrison, A. P., … Craske, M. G. (2018). The lancet psychiatry commission on psychological treatments research in tomorrow's science. The Lancet Psychiatry, 5(3), 237286. doi:S2215-0366(17)30513-8 [pii].
Kosic, A., Lindholm, P., Jarvholm, K., Hedman-Lagerlof, E., & Axelsson, E. (2020). Three decades of increase in health anxiety: Systematic review and meta-analysis of birth cohort changes in university student samples from 1985 to 2017. Journal of Anxiety Disorders, 71, 102208. doi:S0887-6185(20)30022-0 [pii].
Newby, J. M., Smith, J., Uppal, S., Mason, E., Mahoney, A. E. J., & Andrews, G. (2018). Internet-based cognitive behavioral therapy versus psychoeducation control for illness anxiety disorder and somatic symptom disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 86(1), 8998. doi:10.1037/ccp0000248.
Petersen, M. W., Schroder, A., Jorgensen, T., Ornbol, E., Dantoft, T. M., Eliasen, M., & Fink, P. (2019). RIFD – A brief clinical research interview for functional somatic disorders and health anxiety. Journal of Psychosomatic Research, 122, 104111. doi:S0022-3999(19)30045-5 [pii].
Rozental, A., Kottorp, A., Boettcher, J., Andersson, G., & Carlbring, P. (2016). Negative effects of psychological treatments: An exploratory factor analysis of the negative effects questionnaire for monitoring and reporting adverse and unwanted events. PLoS ONE, 11(6), e0157503. doi:10.1371/journal.pone.0157503.
Rozental, A., Magnusson, K., Boettcher, J., Andersson, G., & Carlbring, P. (2017). For better or worse: An individual patient data meta-analysis of deterioration among participants receiving internet-based cognitive behavior therapy. Journal of Consulting and Clinical Psychology, 85(2), 160177. doi:10.1037/ccp0000158.
Rusch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma. European Psychiatry: The Journal of the Association of European Psychiatrists, 20(8), 529539. doi:S0924-9338(05)00090-8 [pii].
Salkovskis, P. M., Rimes, K. A., Warwick, H. M., & Clark, D. M. (2002). The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32(5), 843853.
Sunderland, M., Newby, J. M., & Andrews, G. (2013). Health anxiety in Australia: Prevalence, comorbidity, disability and service use. The British Journal of Psychiatry: The Journal of Mental Science, 202(1), 5661. doi:10.1192/bjp.bp.111.103960.
Thomson, A. B., & Page, L. A. (2007). Psychotherapies for hypochondriasis. The Cochrane Database of Systematic Reviews, (4), CD006520. doi:10.1002/14651858.CD006520.pub2.
Topp, C. W., Ostergaard, S. D., Sondergaard, S., & Bech, P. (2015). The WHO-5 well-being index: A systematic review of the literature. Psychotherapy and Psychosomatics, 84(3), 167176. doi:10.1159/000376585.
van Ballegooijen, W., Cuijpers, P., van Straten, A., Karyotaki, E., Andersson, G., Smit, J. H., & Riper, H. (2014). Adherence to internet-based and face-to-face cognitive behavioural therapy for depression: A meta-analysis. PLoS ONE, 9(7), e100674. doi:10.1371/journal.pone.0100674.
Weck, F., Richtberg, S., & Neng, J. M. (2014). Epidemiology of hypochondriasis and health anxiety: Comparison of different diagnostic criteria. Current Psychiatry Reviews, 10(1), 1423. doi:10.2174/1573400509666131119004444.
World Health Organization, Collaborating Centres for Classification of Diseases. (2014). ICD-10: International statistical classification of diseases and related health problems: Version 2014. Geneva: WHO.

Keywords

Type Description Title
WORD
Supplementary materials

Hoffmann et al. supplementary material
Hoffmann et al. supplementary material 1

 Word (18 KB)
18 KB
WORD
Supplementary materials

Hoffmann et al. supplementary material
Hoffmann et al. supplementary material 2

 Word (19 KB)
19 KB

Efficacy of internet-delivered acceptance and commitment therapy for severe health anxiety: results from a randomized, controlled trial

  • Ditte Hoffmann (a1), Charlotte Ulrikka Rask (a2) (a3), Erik Hedman-Lagerlöf (a4), Jens Søndergaard Jensen (a1) and Lisbeth Frostholm (a1)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.