Interventions for Hypochondriasis in Primary CareInterventions for Hypochondriasis in Primary Care

To the Editor: Drs Barsky and Ahern¹ reported that compared with usual care, a cognitive behavior therapy (CBT) intervention in primary care, enhanced by a letter to the primary care physician that outlined the treatment strategy, improved hypochondriacal beliefs, attitudes, and anxieties, but did not significantly affect hypochondriacal somatic symptoms. I am concerned that the results do not necessarily support the use of this labor-intensive treatment.

First, as the authors pointed out, they could not separate the independent effect of the CBT intervention from that of the consultation letter that was sent to the primary care physician. This letter outlines 5 strategies that have been reported to be effective in previous work.^{2 - 4} Thus, the appropriate comparison intervention would not be usual care, but rather the consultation letter without the CBT intervention.

Second, the results may reflect a social desirability bias. If a patient spends 6 individual counseling sessions with a confidante who tells him or her to think and feel differently, the patient is likely to say that he or she does in fact think and feel differently. This effect may be even more pronounced for patients with hypochondriasis. Such patients may be more likely to have an insecure attachment to others.^{5 - 6} This means that they become more anxious in interpersonal relationships and have a high need to please others, especially those in authority.

Finally, it is interesting that patients reported no change in hypochondriacal somatic symptoms, an outcome that the CBT intervention did not achieve. If patients continue to experience and complain about their somatic concerns, they will continue to seek treatment and unnecessary tests, and the cycle will likely continue.