ACT Group Treatment for Health Anxiety

1. ACT Group Treatment for Health Anxiety An outline of health anxiety, presentation of an ACT group treatment model and preliminary results from a Pilot Study Trine Eilenberg, cand. psych, Ph.D stud, trine.eilenberg@aarhus.rm.dk Lisbeth Frostholm, cand. psych, Ph.D, lisbeth.frostholm@aarhus.rm.dk Louise K. Nielsen, cand. psych, lomani@rm.dk

2. Agenda Mindfulness Exercise Briefly about us! Health Anxiety: The Diagnosis Health Anxiety: The Manual Exercise: ‘The Lifeline’ Preliminary Results Reflections and Questions Mindfulness Exercise

3. Where is Aarhus?

4. x Aarhus University Hospital

5. The Research Clinic for Functional Disorders & Psychosomatics (1999-) • A psychiatric department, but at a General University Hospital • 15-20 employees (medical doctors, psychiatrists, psychologists, anthropologists, a statistician etc.) • Several different research projects • ACT: A ’psycho-educational video for acute whiplash’ + brief intervention

6. Definition: Functional disorders • Conditions where the patient complaints of physical symptoms that cause excessive worry or discomfort or lead the patient to seek treatment, but for which no adequate organ-pathology or patho-physiological basis can be found Fink, 2002

7. Health Anxiety Anne: 35-year-old academic is referred due to a strong, bothersome inclination to always be afraid of being seriously ill. It is especially cancer, but also heart disease. She remembers that already in her childhood, she was very afraid of dying. In her adolescence, some anxiety and feelings of insecurity. During many years a lot of stomach problems corresponding to irritable bowel. The symptoms were aggravated around age 32 when a friend got breast cancer and went through surgery. Has seen her GP frequently and has had a mammogram and a colonoscopy. Cannot believe the GP when he says that she does not need any more examinations. Self-examines her breasts daily and examined her stools for a while. Lately, she has cancelled several social activities due to her ruminations about illness.

8. - If you get thoughts that something may be the matter with you, do you find it difficult to get rid of the thoughts? • Do you think about it almost all the time, or does it get too much at times? Diagnostic criteria for Hypochondriasis / Health anxiety + At least 1 Fink et al Am J Psych 2004

9. A Model for Health Anxiety Sensations/symp- toms Selective attention to specific bodily functions Thoughts Anxiety / Distress Reassurance

10. Prevalence of Hypochondriasis in primary care (n=701/1785) No significant age or gender differences *Without exclusion for other somatoform disorders Fink et al Am J Psych 2004

11. ACT Group Treatment for Health Anxiety (HA) • an ACT group treatment model • Trine Eilenberg, cand. psych, Ph.D stud, trine.eilenberg@aarhus.rm.dk

12. Why ACT for health anxiety? • The usual treatment in DK is regarded as insufficient to patients with HA • HA is persistent and impose a high use of health care. • Only 8 RCT’s on health anxiety (explanatory therapy, cognitive therapy and cognitive behavioral therapy)* • intervention with focus on improvement of coping skills instead of elimination of the somatic symptoms per se. • Emphasis on acceptance and improved functioning rather than symptom reduction per se • ACT has, to our knowledge, not yet been tested in a RCT on patients with health anxiety. *(Fava et al, 2000; Greeven et al, 2007; Visser, 2001; Barsky, 2004; Clark et al, 1998; Warwick et al, 1996; Sorensen et al, 2010; Avia, 1996)

13. Treatment manual The manual: • follows guidelines for the implementation of ACT derived from Hayes et al.,1999 (Acceptance and commitment Therapy, an experiential approach to behavior change); Michael Twohig, 2004 (ACT for OCD); Robert Zettle, 2007 (ACT for Depression). Focus on: • Behavioral exercises throughout all phases • Balance of flexibility and enough structure for research purpose Groups: • Treatment delivered in groups of 9 patients by 2 trained psychologists • 9 weekly sessions of 3½ hours, 1 booster session 1 month after 9. session

14. Real disorder Treatment goals Impact of health anxiety on life Individual perpetuating factors (cognitive, emotional and behavioral) Increasing awareness on flexible and value oriented behavior Relapse prevention /commitment to individual valued action for the next month Introduction to the treatment program What is ACT? Creative hopelessness (Inflexible behavior/thoughts) Control as the problem – not the solution. Willingness Defusion from thought Self-as-context Value clarification Committed action Booster session (how to maintain learned strategies) Manual outline – 10 sessions Phase 1: Creative Hopelessness Phase 2: Willingness & Defusion Phase 3: Values clarification

16. Phase I: Creative hopelessness & early values clarification • Describe health anxiety ”loops” • TRAP exercises to highlight behavioral and experiential avoidance (Trigger > Response > Avoidance Pattern) • Metaphores: Life line, ”Take your thoughts for a walk”, Man in the Hole, Quicksand, Tug of War… • Introduce Mindfulness • Begin to elicit potential value domains and values

17. Phase II: Willingness & Defusion • Control is the Problem, not the Solution • Introduce Willingness as an alternative to avoidance (TRAC; Trigger > Response > Alternative Coping) • Metaphores: The Baby Tiger, Bus Metaphor, Chinese Handcuffs, Your Mind is a Tantrum Child, Willingness and Anxiety Radio Channels, Leaves on a string…. • Foster mindfulness skills, as an alternative to worrying

18. Phase III: Further value clarification and post-treatment planning • More formal value clarification • Thoughts observed as thoughts and thoughts bought as beliefs/concepts • Putting willingness into Action • Metaphores: The Observer Exercise, Objectifying unwanted Thoughts/sensations, Bus Metaphore ”Your Life”, A Long Journey (Funeral exercise), Life Compass • How to get back on the trail when you’ve noticed you’ve wandered off

19. ACT Group Treatment for Health Anxiety • preliminary results from a Pilot Study Trine Eilenberg, cand. psych, Ph.D stud, trine.eilenberg@aarhus.rm.dk

20. Treatment of patients with health anxiety. A randomized controlled trial of ACT group therapy compared with a wait-list.

21. Aim • To compare the effect of ACT in groups with a wait-list on health anxiety at 9 months in patients with severe health anxiety

22. Outcome measures Primary outcome measure: • Health anxiety (illness worry) measured by the Whiteley-7 index Secondary outcome measures: • Psychosocial outcome measures: Social level of functioning, emotional disorders measured with relevant sub-scales from SF-36; SCL 90; CAGE, • illness perception measured with IPQ • physical symptoms measured with somatization subscales from SCL 90. • Health care use and sick days measured by data extraction from different Danish registers • ACT process measure measured by AAQ II and FFMQ.

23. Whiteley-7 index – Illness worrying Fink et al Psychosomatics 1999

24. AAQ-II Psychological Flexibility

25. Preliminary results 4 Pilot groups

26. Results primary outcome – Whiteley Index

27. Results: Comparison with CBT studies

28. Results; AAQ-II

29. Conclusions and research perspectives ACT group treatment • is effective in reducing severe health anxiety • seems as effective as CBT …And we know enough to improve health care for this neglected group of patients!

30. Limitations • ACT group treatment tested in patients with severe health anxiety – effect for patients with less severe illness remains unclear • Highly skilled, enthusiastic therapists – findings require replication

31. Strenghts • Long-term follow-up – effect sizes were sustained during follow-up • Group treatment – more cost-effective? • Representative sample – few patients declined participation, patients were consecutively referred from both primary and secondary care

32. So how’s the leg today? Has it started to itch underneath the plaster? You know, the itch can get almost unbearable once you start thinking about it!

33. References • Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA 2004 Mar 24;291(12):1464-70. • Hayes, S.C., Strosahl, K. Wilson, K.. Acceptance and Commitment Therapy: an experiential approach to behavior change. 1999. New York: Guilford Press. • Twohig MP, Hayes SC, Masuda A. Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behav Ther 2006 Mar;37(1):3-13. • Zettle, R.D. ACT for Depression. A Clinician’s Guide to Using Acceptance & Commitment Therapy in Treatning Depression. 2007. Oakland: New Harbinger Publication, Inc • Fink P, Ørnbøl E, Christensen KS. The Outcome of Health Anxiety in Primary Care. A Two-Year Follow-up Study on Health Care Costs and Self-Rated Health. PLoS ONE 2010 Mar 24;5(3):e9873. • Greeven A, van Balkom AJ, Visser S, Merkelbach JW, van Rood YR, Van Dyck R, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007 Jan;164(1):91-9. • Fava GA, Grandi S, Rafanelli C, Fabbri S, Cazzaro M. Explanatory therapy in hypochondriasis. J Clin Psychiatry 2000 Apr;61(4):317-22. • Visser S, Bouman TK. The treatment of hypochondriasis: exposure plus response prevention vs cognitive therapy. Behav Res Ther 2001 Apr;39(4):423-42. • Clark DM, Salkovskis PM, Hackmann A, Wells A, Fennell M, Ludgate J, et al. Two psychological treatments for hypochondriasis. A randomised controlled trial. Br J Psychiatry 1998 Sep;173:218-25. • Warwick HM, Clarke DM, Cobb AM, Salkovskis PM. A controlled trial of cognitive-behavioural treatment of hypochondriasis. Br J Psychiatry 1996 Aug;169(2):189-95. • Sorensen P, Birket-Smith M, Wattar U, Buemann I, Salkovskis P. A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis.(1469-8978 (Electronic)). • Via MD FAU, Ruiz MA FAU, Olivares ME FAU, Crespo MF, Guisado AB FAU, Sanchez AF, et al. The meaning of psychological symptoms: effectiveness of a group intervention with hypochondriacal patients.(0005-7967 (Print)).

34. Stories from the patients • How has the course been for you until now? • “Excellent! I am much more calm now.” • “It has been interesting to work with health anxiety. It has given me a push in the right direction. It has helped me overcome some barriers.” • “Interesting and unexpected!” • “I have become aware of some “processes” that I have started to work on.”

35. What kind of challenges did you experience during the course until now? • “Staying on the right track and still meeting anxiety in a calm way – (welcoming anxiety).” • “It can be axiety-provoking to work with this. It can be challenging to challenge yourself.” • “The realization that you are not offering a tool for fighting or controlling anxiety. • “Realizing that we need to live with the anxiety without it dominating.” • “Feeling myself and taking anxiety “by the hand”.” • That I thought I would experience a faster result. Now I have realized that it will take some time, and that I have gained more than I was aware of.”