Journal of Consulting and Clinical Psychology © 2014 American Psychological Association

2015, Vol. 83, No. 4, 665– 676 0022-006X/15/$12.00 http://dx.doi.org/10.1037/ccp0000013

Cognitive Therapy Versus Exposure Therapy for Hypochondriasis

(Health Anxiety): A Randomized Controlled Trial
Florian Weck, Julia M. B. Neng, Samantha Richtberg,
Marion Jakob, and Ulrich Stangier
Goethe University

Objective: Cognitive– behavioral therapy has proven to be highly effective in the treatment of hypo-
chondriasis and health anxiety. However, little is known about which therapeutic interventions are most
promising. The aim of the present study was to compare the efficacy of cognitive therapy (CT) with
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

exposure therapy (ET). Method: Eighty-four patients with a diagnosis of hypochondriasis were randomly
This document is copyrighted by the American Psychological Association or one of its allied publishers.

allocated to CT, ET, or a waiting list (WL) control group. The primary outcome measure was a
standardized interview that evaluated hypochondriacal cognitions as well as behaviors conducted by
independent diagnosticians. Several self-report questionnaires were evaluated as secondary outcome
measures. Treatment success was evaluated at posttreatment and at 1-year follow-up. Results: Both CT
(Hedges’s g ⫽ 1.01–1.11) and ET (Hedges’s g ⫽ 1.21–1.24) demonstrated their efficacy in comparison
with the WL in the primary outcome measure. Moreover, a significant reduction in depressive symptoms
and bodily complaints was found in the secondary outcome measures for both treatments in comparison
with the WL, but anxiety symptoms were only significantly reduced by ET. In a direct comparison, no
significant differences were found between CT and ET in the primary or the secondary outcome
measures. Regarding safety behaviors, we found a significantly larger improvement with ET than with
CT in the completer analyses. Conclusions: The results suggest high efficacy of CT as well as ET in the
treatment of hypochondriasis. Cognitive interventions were not a necessary condition for the change of
dysfunctional cognitions. These findings are relevant to the conceptualization and psychotherapeutic
treatment of hypochondriasis and health anxiety.

What is the public health significance of this article?

This study strongly suggests that both cognitive therapy and exposure therapy are effective treat-
ments for hypochondriasis. Moreover, both treatments demonstrated large follow-up effect sizes,
which was a deficit of former studies. Long-term efficacy might be achieved with the implementation
of booster sessions.

Keywords: hypochondriasis, cognitive therapy, exposure therapy, illness anxiety disorder, treatment

Hypochondriasis is characterized by fears of having a serious
illness (e.g., cancer; American Psychiatric Association, 2000).
While hypochondriasis describes the clinical syndrome, health
anxiety refers to the full range of dysfunctional health concerns
(see Marcus, Gurley, Marchi, & Bauer, 2007). Differences be-
tween hypochondriasis and health anxiety were found to be quan-
titative rather than qualitative (Ferguson, 2009; Longley et al.,
2010). Therefore, empirical findings for hypochondriasis can be
considered as relevant for health anxiety and vice versa.
This article was published Online First December 15, 2014.
Florian Weck, Julia M. B. Neng, Samantha Richtberg, Marion Jakob,
and Ulrich Stangier, Department of Clinical Psychology and Psychother-
apy, Goethe University.
This research was supported by Grants WE 4654/2-1 and WE4654/2-3
from the German Research Foundation.
Correspondence concerning this article should be addressed to Florian
Weck, Department of Clinical Psychology and Psychotherapy, Goethe
University, Varrentrappstr, 40-42, 60486 Frankfurt am Main, Germany.
E-mail: weck@psych.uni-frankfurt.de
In a recent literature review of 55 articles, the prevalence of
hypochondriasis was found to be 0.40% (range ⫽ 0.0 –4.5%) in the
general population and 2.95% (range ⫽ 0.3–8.5%) in general
medical settings (Weck, Richtberg, & Neng, 2014). Hypochondri-
asis is associated with clinically significant distress, high persis-
tence of the diagnosis, and high costs for the healthcare system
(e.g., Fink, Ørnbøl, & Christensen, 2010). Fortunately, cognitive–
behavioral therapy (CBT) has been demonstrated to be a highly
effective approach for the treatment of hypochondriasis and health
anxiety. In a recent meta-analysis that included 13 randomized
controlled trials (RCTs) with a total sample size of 1,081 partici-
pants, CBT showed large effect sizes (Hedges’s g ⫽ 0.95) in
comparison with control conditions on primary outcome measures
(Olatunji et al., 2014). In that study, primary outcome measures
were exclusively measures of hypochondriasis/health anxiety,
which often include cognitive as well as behavioral aspects. CBT
also has a positive effect on the comorbid depressive and anxiety
symptoms (Olatunji et al., 2014; Thomson & Page, 2007) that
frequently co-occur with hypochondriasis and health anxiety (e.g.,
Sunderland, Newby, & Andrews, 2013). Moreover, CBT has dem-

665
 666 WECK, NENG, RICHTBERG, JAKOB, AND STANGIER
onstrated lasting efficacy in follow-up analyses; however, effect
sizes were significantly smaller than at posttreatment (Hedges’s
g ⫽ 0.34; Olatunji et al., 2014). Furthermore, in one RCT that
included 80 patients with hypochondriasis, CBT was superior to
psychodynamic psychotherapy at reducing health anxiety and de-
pressive symptoms (Sørensen, Birket-Smith, Wattar, Buemann, &
Salkovskis, 2011).
Even though there is evidence that CBT is highly effective in
the treatment of hypochondriasis and health anxiety, it is un-
clear which interventions of CBT are the most promising as of
yet (Thomson & Page, 2007). The prominent cognitive–
behavioral model of hypochondriasis and health anxiety of
Warwick and Salkovskis (1990) illustrates that the illness-
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related misinterpretation of bodily symptoms leads to an in-
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creased focus on the body, physiological arousal, and safety
behaviors. Those bodily changes and behaviors strengthen the
dysfunctional beliefs about one’s own illness, which in turn
produces further physiological symptoms and safety behaviors,
and so on. This circular model shows many similarities with
cognitive– behavioral theories of anxiety disorders such as
panic disorder (see Salkovskis & Clark, 1993). Processes such
as safety behaviors, selective attention, and misinterpretations
are specifically considered to be highly relevant for the main-
tenance of hypochondriasis and anxiety disorders. These com-
mon processes are also important for the conceptualization of
psychological treatment approaches. Moreover, phenomenolog-
ical similarities between hypochondriasis and anxiety disorders,
such as a comparable level of anxiety, are strongly supported by
empirical findings, with the strongest similarities found for
panic disorder (e.g., Abramowitz, Olatunji, & Deacon, 2007;
Deacon & Abramowitz, 2008; Gropalis, Bleichhardt, Witthöft,
& Hiller, 2012; Hiller, Leibbrand, Rief, & Fichter, 2005; Neng
& Weck, 2013; van den Heuvel et al., 2005; Weck, Bleichhardt,
Witthöft, & Hiller, 2011; Weck, Neng, Richtberg, & Stangier,
2012). The phenomenological similarities between hypochon-
driasis and anxiety disorders are also important for choosing
and developing effective treatment strategies (e.g., addressing
anxiety with exposure). Because of the similarities between
hypochondriasis and anxiety disorders, the perspective of hy-
pochondriasis as a somatoform disorder instead of an anxiety
disorder in the Diagnostic and Statistical Manual of Mental
Disorders (DSM) was criticized and it was emphasized that as
a result of this classification, “there has been a noticeable delay
in the development of theoretically grounded paradigms for
understanding and treating hypochondriasis” (Olatunji, Deacon,
& Abramowitz, 2009; p. 482). When we take into account that
hypochondriasis has much in common with anxiety disorders,
exposure therapy (ET) can be considered an important approach
for the treatment of hypochondriasis. While cognitive therapy
(CT) has a focus on changing dysfunctional cognitions, ET is a
behavioral treatment approach that includes the exposure of the
patient to the feared object or situation to overcome the anxiety.
Based on systematic investigations, the first evidence for the
efficacy of ET was found in a randomized controlled pilot trial that
included 17 patients with hypochondriasis (Bouman & Visser,
1998). In this study, a similar efficacy of ET and CT was found;
however, no independent control group was used and the sample
size was small. Subsequently, in a more comprehensive investiga-
tion by Visser and Bouman (2001), the efficacy of ET in compar-
ison with CT and a waiting list (WL) control group was investi-
gated in 78 patients with hypochondriasis. Active treatments
included 12 weekly sessions in a 3-month period. Treatment out-
come was assessed four times (pretreatment, posttreatment,
1-month follow-up, and 7-month follow-up). ET and CT demon-
strated their efficacy in comparison with the WL, but no differ-
ences were found between ET and CT on the main outcome
measure (Illness Attitude Scales). However, on idiosyncratic
scales (visual analogue scales) that evaluate cognitive aspects (i.e.,
the five main hypochondriacal cognitions of each individual pa-
tient, rated 0 –100% on conviction) and on depressive measures
(Beck Depression Inventory), there was a trend that the improve-
ment was larger in the CT group than in the ET group. Several
limitations, however, restrict the generalizability of the findings.
First, treatment integrity (i.e., therapists’ adherence and compe-
tence) was not evaluated, which limits the internal and external
validity of the study (e.g., Perepletchikova, Treat, & Kazdin,
2007). Second, therapy outcome was only assessed by question-
naires and not by independent diagnosticians. Third, ET did not
include exposure in sensu, which can be considered an important
exposure-based intervention (Furer & Walker, 2005, 2008; Wit-
thöft & Hiller, 2010). Fourth, there was a high dropout rate (28%),
which calls into question the acceptability of the treatments, and
only completers were included and no intention-to-treat analyses
were conducted. Finally, the follow-up evaluation was adminis-
tered only 7 months after treatment and a longer follow-up period
would be desirable.
Those limitations do not allow the satisfactory evaluation of the
importance of cognitive approaches in comparison with behavioral
approaches (i.e., exposure) for the treatment of hypochondriasis.
On the other hand, the question of the role of cognitive versus
behavioral interventions for the treatment of hypochondriasis is of
high relevance for theoretical (e.g., maintenance of the disorder)
and practical (e.g., treatment recommendations) reasons. There-
fore, further research that considers cognitive approaches in com-
parison with behavioral approaches and that addresses the limita-
tions of the previous studies is necessary.
The aim of the current study was to investigate the efficacy
of ET and CT compared with a control condition (i.e., WL) in
a randomized controlled study design. We hypothesized that ET
and CT would lead to a significant reduction in dysfunctional
health-related cognitions and behaviors relative to the WL
(Hypothesis 1). We hypothesized that both CT and ET would
lead to a significant reduction in anxiety, depression, and bodily
symptoms in comparison with the WL (Hypothesis 2). More-
over, we hypothesized that both CT and ET would demonstrate
maintenance of treatment effects at the 12-month follow-up
(Hypothesis 3). Regarding differences between CT and ET, we
expected that CT would be more effective in changing hypo-
chondriacal cognitions and that ET would be more effective in
changing hypochondriacal behaviors (i.e., avoidance, reassur-
ance seeking) at posttreatment (Hypothesis 4). In line with this
hypothesis, previous research has found some evidence for the
superiority of CT in reducing hypochondriacal cognitions (Vis-
ser & Bouman, 2001). However, in the long run it can be
expected that differences between CT and ET are less pro-
nounced because the reduction in dysfunctional health-related
cognitions would lead to a reduction in health-related behavior
and vice versa (see Warwick & Salkovskis, 1990).
 COGNITIVE THERAPY VERSUS EXPOSURE THERAPY 667

Method
Participants
Participants were recruited between June 2010 and February
2013 from among treatment-seeking individuals at the outpatient
unit of the Department of Clinical Psychology and Psychotherapy
at the Goethe University Frankfurt in Germany. Information about
the study was given in the local newspapers, on the radio, and via
the Internet. Inclusion criteria of the current study were (a) age
between 18 and 65 years, (b) meeting the DSM–IV criteria of
hypochondriasis, (c) fluency and literacy in German, and (d)
informed consent. Exclusion criteria were (a) a major medical
illness (e.g., cancer), (b) acute suicidal tendencies, and (c) the
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tions, they were required to have had a stable dose for at least five
weeks prior to treatment.
The participant flowchart is displayed in Figure 1. The 84
allocated participants ranged from 18 to 65 years old and had an
average age of 40.05 (SD ⫽ 11.82) years. Fifty (59.52%) of the
participants were female. The majority of the sample had qualifi-
cations for university entrance (64.29%) and was married or co-
habiting (76.19%). Almost all participants were Caucasian
(98.81%) and one patient was Latino. Participants declared that
they suffered from health anxieties for a mean of 13.61 (SD ⫽
12.37) years. The most feared diseases were cancer (67.86%),
cardiovascular diseases (28.57%), infectious diseases (10.71%),
and neurological diseases (9.52%). Forty-four (52.38%) of the

clinical diagnosis of substance addiction, schizophrenia or schizo- participants had at least one comorbid disorder. Comorbid diag-
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affective disorder, or bipolar disorder according to the Structured noses were most often anxiety disorders, for which 30 (35.71%) of
Clinical Interview for DSM–IV (SCID; First, Spitzer, Gibbon, & the participants met criteria (13 panic disorder, 10 specific phobia,
Williams, 1997). If participants received psychotropic medica- five obsessive– compulsive disorder, two social phobia, and two

Completed telephone
screening (n=320) Excluded (n=185)
- Not meeting inclusion criteria
(n=128)
Enrollment

- Declined participation (n=57)

Completed face-to-face
screening (n=135)
Excluded (n=39)
- Not meeting inclusion criteria
(n=35)
- Declined participation (n=4)
Completed SCID (n=96)
Excluded (n=12)
- Not meeting inclusion criteria
(n=10)
- Declined participation (n=2)
Randomized to Treatment
(n=84)
Allocation

Allocated to CT (n=21) Allocated to Wait Allocated to ET (n=21)

- drop-out (n=2) List (n=42) - drop-out (n=2)
- drop-out (n=7)

Completed CT (n=19)
Post-treatment Assessment

Completed Wait List Completed ET (n=19)

(n=35)

Randomized to CT (n=17) Randomized to ET (n=16)

- drop-out (n=1)
Total CT completers ( n=35)
Eligible for follow-up
Follow-up
No longer fulfilled the - drop-out (n=2)
diagnosis of
hypochondriasis after
wait list (n=2)
Total ET completers ( n=33)
Eligible for follow-up

Completed 12-month follow- Completed 12-month follow-

up (n=30) up (n=29)
- lost at follow-up (n=4) - lost at follow-up (n=4)

Figure 1. Flowchart of participants. CT ⫽ cognitive therapy; ET ⫽ exposure therapy; SCID ⫽ Structured

Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
 668 WECK, NENG, RICHTBERG, JAKOB, AND STANGIER
generalized anxiety disorder), and affective disorders, which 18
(21.43%) met criteria for. Fourteen (16.67%) of the participants
received an antidepressant medication, most often a selective se-
rotonin reuptake inhibitor (8.33%).
Measures
Diagnoses. The SCID was used to establish the diagnoses.
Experienced clinicians who were trained in a 2-day SCID work-
shop acted as diagnosticians. Diagnosticians were blind to the
treatment status. All diagnostic interviews were video recorded.
Twenty percent (n ⫽ 17) of the assessments were selected ran-
domly and rated by a second diagnostician for information about
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reliability. The agreement between diagnosticians was high (␬ ⫽
This document is copyrighted by the American Psychological Association or one of its allied publishers.
.854; p ⬍ .001).
Primary outcome measure. The Yale–Brown Obsessive
Compulsive Scale for Hypochondriasis (H-YBOCS; Weck, Gro-
palis, Neng, & Witthöft, 2013) was used as the primary outcome
measure because it has been demonstrated to be a reliable and
valid clinical interview for the assessment of cognitions and be-
haviors in hypochondriasis. Assessors of the H-YBOCS were blind
to the treatment status. The H-YBOCS is a 12-item clinician-
administered interview comprising three scales (cognitive, behav-
ioral, and insight), each rated on a 5-point scale (0 – 4; response
format depends on the question). One example item of the
H-YBOCS is as follows: “Distress associated with thoughts related
to illness.” In the current study, the cognitive scale (five items) and
the behavioral scale (five items) of the H-YBOCS were used to
assess dysfunctional health-related cognitions and behaviors. The
interrater reliability (i.e., intraclass correlation coefficient [ICC])
of the H-YBOCS in the current study was evaluated on the basis
of n ⫽ 30 video-recorded interviews and was ICC(2,2) ⫽ .97 for
the cognitive and ICC(2,2) ⫽ .98 for the behavioral scales. More-
over, the cognitive (Cronbach’s alpha ⫽ .70) and the behavioral
(Cronbach’s alpha ⫽ .73) scales of the H-YBOCS demonstrated
satisfactory internal consistency in the current study.
Secondary outcome measures. Several standardized self-
report measures were used for the evaluation of hypochondriacal
characteristics and general psychopathology.
Illness Attitudes Scales (IAS; Kellner, 1986; German version:
Hiller, Rief, & Fichter, 2002). The IAS consists of 27 items
(e.g., “Do you worry about your health?”), each rated on a 5-point
rating scale, ranging from 0 (no) to 4 (most of the time). The IAS
is an internationally well-established questionnaire for the assess-
ment of hypochondriacal attributes that has demonstrated good
reliability and validity (Sirri, Grandi, & Fava, 2008). The IAS had
high internal consistency in the current study (Cronbach’s alpha ⫽
.87).
Cognitions About Body and Health Questionnaire (CABAH;
Rief, Hiller, & Margraf, 1998). The CABAH was used for the
assessment of cognitions that are relevant for the maintenance of
hypochondriasis (e.g., “Bodily complaints are always a sign of
disease”). The items of the CABAH are rated on a 4-point scale,
ranging from 0 (completely wrong) to 3 (completely right). We
used a 28-item version of the CABAH (items of the subscale
health habits were excluded because they failed to demonstrate
validity; Rief et al., 1998), which showed good reliability and
validity. The CABAH demonstrated high internal consistency in
the current study (Cronbach’s alpha ⫽ .86).
Questionnaire for Assessing Safety Behavior in Hypochondri-
asis/Health Anxiety (QSBH; Weck, Brehm, & Schermelleh-
Engel, 2012). The QSBH was used for the assessment of hypo-
chondriacal safety behaviors (reassurance and avoidance). An
example item of the QSBH is as follows: “Do you check if you
look healthy in the mirror?” The QSBH consists of 16 items, each
rated on a 5-point rating scale, ranging from 0 (never) to 4 (very
frequently). In the current study, the internal consistency of the
QSBH was Cronbach’ s ␣ ⫽ .78.
Patient Health Questionnaire (PHQ-15; Spitzer, Kroenke, &
Williams, 1999; German version: Löwe, Spitzer, Zipfel, & Her-
zog, 2002). The PHQ-15 was used for the evaluation of 15
somatoform symptoms (assessed by 13 items; e.g., “headache”),
each rated on a 3-point rating scale, ranging from 0 (not bothered
at all) to 2 (bothered a lot). In the current study, the internal
consistency of the PHQ-15 was Cronbach’s alpha ⫽ .78.
Beck Depression Inventory-II (BDI-II; Beck & Steer, 1996;
German version: Hautzinger, Keller, & Kühner, 2006). The
BDI-II was used for the evaluation of depressive symptoms. The
instrument consists of 21 items. In the current study, the internal
consistency of the BDI-II was Cronbach’s alpha ⫽ .87.
Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer,
1988; German version: Margraf & Ehlers, 2007). The BAI is a
21-item questionnaire that was used for the assessment of anxiety
symptoms. In the current study, the Cronbach’s alpha of the BAI
was .92.
Procedures
This trial was registered at ClinicalTrials.gov (NCT01119469).
The study protocol was approved by the Institutional Review
Board of the University Hospital Frankfurt and written informed
consent was given by all participants. Potential study candidates
were screened via telephone and a face-to-face interview for the
criteria of a DSM–IV diagnosis of hypochondriasis (American
Psychological Association, 2000) and the inclusion/exclusion cri-
teria. Persons who reported symptoms in line with the DSM–IV
criteria for hypochondriasis and who met the inclusion criteria
received a diagnostic interview using the SCID. Eligible partici-
pants were randomly assigned to CT, ET, or the WL (1:1:2).
Participants who were assigned to the WL were randomized af-
terward to CT or ET (see Figure 1).
Interventions
Both treatments included 12 regular sessions (attended weekly)
and three booster sessions (applied 1, 3, and 6 months after the last
regular treatment session), each lasting 50 min. The CT and ET
interventions are described in detail in a treatment manual. Treat-
ments were conducted by 27 Master’s degree clinical psycholo-
gists (22 females and five males) who had a mean of 2.62 (SD ⫽
1.09; range ⫽ 1.4 –6.6) years of clinical experience after their
Master’s degree. Most (24; 88.98%) of the therapists were in
psychotherapy training and three (11.11%) were licensed psycho-
therapists. Therapists were trained via workshops for a total of 24
hr in the underlying theory and practical elements of the treatment
using videotapes and role playing. Therapists received regular
 COGNITIVE THERAPY VERSUS EXPOSURE THERAPY
supervision at least once per month by F.W. (ET) and U.S. (CT),
who are both experts in the administered treatments.
Cognitive therapy (CT). CT aimed to change the cognitive
processes that are considered relevant for the maintenance of heath
anxieties (i.e., selective attention to bodily symptoms, dysfunc-
tional beliefs about symptoms and illnesses). Session 1 included
information about the clinical picture of hypochondriasis (e.g.,
criteria of hypochondriasis, continuum of health anxieties, possible
risk factors). Information was given that common physical sensa-
tions (e.g., a tingling sensation) could enter awareness through
selective attention and could then become the object of health
anxieties. In Sessions 2 and 3, behavioral experiments were used to
demonstrate the importance of selective attention to bodily symp-
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toms for the maintenance of health anxieties. An idiosyncratic
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model based on information processing in hypochondriasis was
established. Attention-related exercises were used to shift attention
from internal bodily sensations to external auditory stimuli (see
Papageorgiou & Wells, 1998). Sessions 4 to 11 focused on the
reduction of dysfunctional health-related beliefs and included the
following interventions: psychoeducation (e.g., information about
the autonomic nervous system), cognitive restructuring of dysfunc-
tional health-related automatic thoughts and beliefs, behavioral
experiments to demonstrate the negative aspects of safety behav-
iors, and imagery rescripting for the modification of intrusive
images. A more detailed description of the interventions is given
elsewhere (Weck, 2014). Session 12 focused on relapse prevention
and included a discussion of how to establish techniques for the
time after treatment.
Exposure therapy (ET). ET aimed to expose the patients to
stimuli that are relevant for health anxieties (e.g., documentaries
about diseases) and to reduce avoidance behaviors (e.g., avoiding
funerals) and safety behaviors (e.g., reassurance by doctors, check-
ing the abdomen for cancer). As in CT, Session 1 included infor-
mation about the clinical picture of hypochondriasis. The roles of
avoidance and safety behaviors for the maintenance of health
anxieties were discussed with the patient. Sessions 2 to 4 focused
on the reduction of safety behaviors (i.e., body checking, reassur-
ance, and doctor visits). Patients were to reduce their safety be-
haviors step-by-step. Occurring problems were discussed with the
therapist. Sessions 5 to 11 included the implementation of the
treatment rationale for exposure (i.e., exposure to health-related
stimuli, without using safety behaviors, leads to a reduction of
health anxieties). Exercises of exposure included interoceptive
exposure (e.g., hyperventilation), exposure in vivo (e.g., viewing
documentaries about illness), and exposure in sensu (e.g., being
confronted with images of being ill and one’s own death; see Furer
& Walker, 2008, 2005). A more detailed description of the inter-
vention is given elsewhere (Weck, Ritter, & Stangier, 2012). As in
CT, Session 12 focused on relapse prevention and included the
discussion on how to use exposure techniques for the time after
treatment.
Wait list (WL). After 3 months, participants received a diag-
nostic interview (i.e., SCID and H-YBOCS) and completed the
self-report measures.
Treatment Integrity
Therapy sessions of all patients who started treatment were
included in the evaluation of therapists’ adherence and compe-
669
tence. A total of 150 videotaped therapy sessions (76 of CT and 74
of ET) were each rated by two Master’s level clinical psycholo-
gists. Raters received a 20-hr training course on how to apply the
adherence and competence scales by evaluating and discussing
therapy sessions that were not part of the current study. For each
patient, two treatment sessions (Sessions 3 and 7 for CT and
Sessions 3 and 8 for ET) were selected for the evaluation of
therapists’ adherence and competence.
Therapists’ adherence. Therapists’ adherence was rated with
a 17-item rating scale that aimed to evaluate whether specific
interventions described in the treatment manuals were applied
during the treatment sessions. The adherence scale has a 3-point
rating scale (0 ⫽ not adherent, 1 ⫽ partly adherent, and 2 ⫽
adherent) and consists of nine items that evaluate aspects of
adherence that are intended in both treatment conditions (agenda,
time management, use of materials, setting homework, reviewing
homework, giving information, identification of safety behaviors,
reduction of safety behaviors, and relapse prophylaxis). Three
items are intended only in ET but are forbidden in CT (giving a
rationale for exposure, developing an anxiety hierarchy, guiding
exposure exercises) and four items are intended only in CT but are
forbidden in ET (elaborating a cognitive model of hypochondria-
sis, attention-related exercises, guiding behavior experiments, and
modification of automatic thoughts). One item is forbidden in both
treatment conditions (interventions from other therapeutic ap-
proaches, such as psychodynamic interventions). The interrater
reliability between the two raters of the mean score of all 17
adherence items was high, ICC(2,2) ⫽ .78; p ⬍ .001.
The mean score of intended interventions was high (CT: M ⫽
1.67; SD ⫽ 0.24; ET: M ⫽ 1.67; SD ⫽ 0.20), and the mean
score of forbidden interventions was low (CT: M ⫽ 0.11; SD ⫽
0.21; ET: M ⫽ 0.06; SD ⫽ 0.13) in both treatments. The purity
index (Luborsky, McLellan, Woody, O’Brien, & Auerbach,
1985), which reflects the ratio of the intended interventions to
the presence of intended plus unintended interventions, was
0.94 (SD ⫽ 0.10) in CT and 0.96 (SD ⫽ 0.07) in ET, which is
very high.
Therapists’ competence. Therapists’ competence was evalu-
ated with the Cognitive Therapy Scale (CTS; Young & Beck,
1980; German version: Weck, Hautzinger, Heidenreich, &
Stangier, 2010). The scale format of the CTS is a 7-point rating
scale (0 ⫽ poor, 1 ⫽ barely adequate, 2 ⫽ mediocre, 3 ⫽
satisfactory, 4 ⫽ good, 5 ⫽ very good, and 6 ⫽ excellent). The
German version of the CTS consists of 14 items (agenda setting,
dealing with problems/questions/objections, clarity of communi-
cation, pacing and efficient use of time, interpersonal effective-
ness, resource activation, reviewing previously set homework,
using feedback and summaries, guided discovery, focus on central
cognitions and behavior, rationale, selecting appropriate strategies,
appropriate implementation of techniques, and assigning home-
work). The interrater reliability of the CTS mean score between the
two raters was high, ICC(2,2) ⫽ .79; p ⬍ .001.
Treatments in the CT (M ⫽ 3.80; SD ⫽ 0.81) and ET (M ⫽
3.62; SD ⫽ 0.74) conditions did not differ significantly in the level
of competence in the CTS mean score, F(1,76) ⫽ 1.94; p ⫽ .17.
According to Shaw et al. (1999), the level of competence is
satisfactory in both treatments.
 670 WECK, NENG, RICHTBERG, JAKOB, AND STANGIER
Statistical Analyses
Analyses were conducted with both the completer (N ⫽ 73) and
the intent-to-treat (ITT) sample (N ⫽ 84). When addressing miss-
ing data, last observations were carried forward. The results of ITT
analyses are reported in the text and results of completer analyses
are only reported when they differ from the ITT analyses. The
results of ITT and completer analyses are displayed in Tables 1
and 2. In preliminary analyses, a series of analyses of variance
(ANOVAs) and chi-square analyses were conducted to analyze
possible differences in pretreatment symptoms and demographic
characteristics.
A priori power analyses were conducted using GⴱPower (Faul,
Erdfelder, Buchner, & Lang, 2009). In meta-analyses, large effect
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sizes were found between psychotherapy and WL control groups
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(Olatunji et al., 2014; Thomson & Page, 2007). To detect a large
effect (.80) at a power of 1 – ␤ ⫽ 0.90 with an ␣ of .05, a sample
of at least 83 participants is needed.
We used a two-stage strategy for the data analyses of treatment
effects. In the first stage, analyses of covariance (ANCOVAs) with
posttreatment scores as the dependent variable, pretreatment scores
as a covariate, and group (CT, ET, and WL) as the independent
variable were conducted. Differences between the three conditions
during each treatment phase were investigated with post hoc
comparisons. In the second stage, repeated analyses of variance
(ANOVAs)1 with two groups (CT and ET) and three times (pre,
post, and follow-up) were conducted. Those analyses also included
the participants who were initially allocated to the WL and sub-
sequently randomized to the active treatment conditions.
Results
Preliminary Analyses
No significant differences between the three groups (CT, ET,
and WL) were found for sociodemographic variables or other
diagnoses: sex (p ⫽ .641), age (p ⫽ .337), educational level (p ⫽
.943), and number of comorbid diagnoses (p ⫽ .348). No differ-
ences were found between the groups in the number of dropouts
(p ⫽ .625) or the taking of antidepressant medication (p ⫽ .152).
We found no significant difference between the groups on any
outcome variable at pretreatment for the whole sample (N ⫽ 84):
H-YBOCS cognitive (p ⫽ .111), H-YBOCS behavioral (p ⫽
.812), IAS (p ⫽ .569), CABAH (p ⫽ .836), QSBH (p ⫽ .463),
PHQ-15 (p ⫽ .660), BDI-II (p ⫽ .263), and BAI (p ⫽ .284).
Furthermore, no significant differences were found between the
CT and ET group for the patients who were considered in the
second stage analyses (N ⫽ 68) in the pretreatment outcome
measures: H-YBOCS cognitive (p ⫽ .827), H-YBOCS behavioral
(p ⫽ .428), IAS (p ⫽ .737), CABAH (p ⫽ .693), QSBH (p ⫽
.256), PHQ-15 (p ⫽ .248), BDI-II (p ⫽ .577), and BAI (p ⫽ .382).
Comparison Between Cognitive Therapy, Exposure
Therapy, and Wait List
Primary outcome measures. ANCOVAs revealed a signifi-
cant main effect of treatment group on the cognitive and behav-
ioral subscales of the H-YBOCS (see Table 1). Post hoc pairwise
comparisons of the posttreatment scores of the cognitive subscale
showed significant differences between CT and the WL (p ⬍ .001)
and between ET and the WL (p ⬍ .001), but not between CT and
ET (p ⫽ .756). Post hoc pairwise comparisons of the posttreatment
scores of the behavioral subscale showed significant differences
between CT and the WL (p ⫽ .002) and between ET and the WL
(p ⬍ .001), but not between CT and ET (p ⫽ .440).
Secondary outcome measures. ANCOVAs revealed a signif-
icant main effect of treatment group on all secondary outcome
measures (see Table 1). Post hoc pairwise comparisons for post-
treatment scores for all measures showed significant differences
between CT and the WL and between ET and the WL, but not
between CT and ET. However, for the BAI, differences between
CT and the WL were only significant by trend (p ⫽ .074).
Comparison Between Cognitive Therapy and Exposure
Therapy for the Outcomes at Posttreatment and
Follow-up
Primary outcome measures. The results are shown in Table
2. For the cognitive subscale of the H-YBOCS, there was a
significant main effect of time, F(2, 66) ⫽ 80.98; p ⬍ .001, but not
of group, F(1, 66) ⫽ 0.31; p ⫽ .582, or of the Time ⫻ Group
interaction, F(2, 66) ⫽ 0.5; p ⫽ .954. For the behavioral subscale,
there was a significant main effect of time, F(2, 66) ⫽ 54.87; p ⬍
.001, but not of group, F(1, 66) ⫽ 0.00; p ⫽ .968, or of the Time ⫻
Group interaction, F(2, 66) ⫽ 1.51; p ⫽ .226. Pre-follow-up effect
sizes were large for the cognitive subscale (CT: Hedges’s g ⫽
1.67; ET: Hedges’s g ⫽ 1.64) as well as for the behavioral
subscale (CT: Hedges’s g ⫽ 1.43; ET: Hedges’s g ⫽ 1.56) of the
H-YBOCS.
We also computed the effect sizes between CT and ET for the
subsample of patients with a comorbid anxiety disorder (n ⫽ 23).
For the cognitive subscale of the H-YBOCS, the Hedges’s gs were
0.00 at post as well as at follow-up. For the behavioral subscale of
the H-YBOCS, the Hedges’s gs were 0.48 at post and ⫺0.29 at
follow-up. No significant Time ⫻ Group interactions were found.
Secondary outcome measures. For all secondary measures,
there was a significant main effect of time, but no significant group
effect nor significant Time ⫻ Group interactions. Only in the
completer analyses was a significant Time ⫻ Group interaction
found for the QSBH (p ⫽ .010). This indicates a trend of a larger
reduction in hypochondriacal safety behaviors in the ET group
than in the CT group. Pre-follow-up effect sizes were large for
most of the secondary outcome measures for CT (IAS: Hedges’s
g ⫽ 1.31; CABAH: Hedges’s g ⫽ 1.07; QSBH: Hedges’s g ⫽
0.92; PHQ-15: Hedges’s g ⫽ 0.86; BAI: Hedges’s g ⫽ 0.72;
BDI-II: Hedges’s g ⫽ 1.00) as well as for ET (IAS: Hedges’s g ⫽
1.38; CABAH: Hedges’s g ⫽ 0.98; QSBH: Hedges’s g ⫽ 1.05;
PHQ-15: Hedges’s g ⫽ 0.50; BAI: Hedges’s g ⫽ 0.51; BDI-II:
Hedges’s g ⫽ 0.56).
We also computed the effect sizes for the secondary outcome
measures between CT and ET for the subsample of patients with a
comorbid anxiety disorder (n ⫽ 23) at post (IAS: Hedges’s
1
Repeated ANOVAs that included the level of therapist competence
(CTS mean score) as a covariate are alternative methods of analysis that
were also conducted and revealed identical results. Thus, we found no
significant interaction between Time ⫻ Group or between Time ⫻ Level
of competence.
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Table 1
Mean Scores and Standard Deviations of Primary and Secondary Outcome Measures at Pre- and Posttreatment, Results of the Analyses of Covariance, and Effect Sizes of
the Intention-to-Treat and Completer Samples

CT M (SD) ET M (SD) WL M (SD) ANCOVA Hedges’s g

Measures Pre Post Pre Post Pre Post F p CT–WL ET–WL

Intention-to-treat sample (N ⫽ 84)

Primary outcome measure
H-YBOCS
Cognitive 11.90 (2.70) 6.43 (3.33) 10.19 (3.04) 5.95 (3.33) 11.90 (2.70) 10.62 (4.21) 13.46 ⬍.001 1.06 1.20
Behavioral 9.90 (3.24) 4.76 (4.21) 9.43 (3.85) 3.52 (3.93) 10.07 (3.90) 8.43 (4.96) 10.46 ⬍.001 0.78 1.07
Secondary outcome measures
IAS 71.97 (15.39) 53.89 (19.21) 71.41 (14.99) 53.35 (16.71) 75.08 (14.13) 72.84 (14.44) 19.07 ⬍.001 1.17 1.27
CABAH 35.25 (10.54) 27.19 (12.69) 33.24 (11.67) 22.21 (9.24) 35.35 (10.54) 33.36 (9.25) 12.36 ⬍.001 0.59 1.21
QSBH 30.20 (9.51) 23.05 (9.14) 31.80 (12.34) 21.10 (10.97) 33.53 (9.30) 34.05 (9.40) 21.72 ⬍.001 1.18 1.29
PHQ-15 9.02 (4.55) 6.67 (3.71) 8.04 (3.92) 5.94 (4.04) 7.89 (5.15) 8.19 (5.29) 5.30 .007 0.31 0.46
BAI 20.24 (12.58) 14.67 (8.10) 15.67 (11.59) 10.90 (10.73) 19.70 (12.07) 18.70 (12.33) 3.33 .041 0.36 0.66
BDI-II 13.48 (7.76) 8.00 (7.52) 11.10 (7.39) 5.71 (5.51) 14.67 (8.58) 12.95 (8.31) 7.61 .001 0.61 0.98

Completer sample (N ⫽ 73)

Primary outcome measure
H-YBOCS
Cognitive 12.11 (2.42) 6.05 (2.99) 10.21 (3.19) 5.53 (3.52) 11.50 (3.07) 10.24 (4.12) 14.04 ⬍.001 1.11 1.21
Behavioral 9.63 (3.08) 3.95 (3.31) 9.17 (3.88) 2.94 (3.61) 10.32 (3.76) 8.50 (5.01) 13.08 ⬍.001 1.01 1.24
Secondary outcome measures
IAS 70.79 (15.30) 49.40 (16.76) 71.14 (14.64) 50.80 (15.02) 74.30 (15.05) 71.62 (15.23) 21.36 ⬍.001 1.41 1.37
CABAH 33.19 (8.94) 23.78 (9.17) 33.74 (11.77) 21.54 (8.94) 33.50 (11.10) 32.41 (9.28) 13.71 0.93 1.19
COGNITIVE THERAPY VERSUS EXPOSURE THERAPY

⬍.001
QSBH 30.79 (9.16) 22.44 (8.69) 32.14 (12.95) 20.32 (11.27) 33.20 (9.87) 33.82 (10.00) 21.08 ⬍.001 1.19 1.28
PHQ-15 9.25 (4.49) 6.50 (3.49) 8.21 (4.09) 5.88 (4.25) 7.57 (5.07) 7.91 (5.26) 4.61 .013 0.30 0.42
BAI 20.44 (13.15) 13.94 (7.78) 16.05 (11.92) 10.78 (11.06) 19.61 (12.47) 18.41 (12.75) 2.96 .059 0.49 0.67
BDI-II 13.67 (7.33) 7.28 (6.77) 11.27 (7.77) 5.32 (5.65) 14.84 (8.89) 12.77 (8.57) 7.53 .001 0.79 1.01
Note. CT ⫽ cognitive therapy; ET ⫽ exposure therapy; WL ⫽ wait list; ANCOVA ⫽ analyses of covariance; Pre ⫽ pretreatment; Post ⫽ posttreatment; H-YBOCS ⫽ Yale–Brown Obsessive
Compulsive Scale for Hypochondriasis; IAS ⫽ Illness Attitudes Scales; CABAH ⫽ Cognitions About Body and Health Questionnaire; QSBH ⫽ Questionnaire for Assessing Safety Behavior in
Hypochondriasis/Health Anxiety; PHQ-15 ⫽ Patients Health Questionnaire; BAI ⫽ Beck Anxiety Inventory; BDI-II ⫽ Beck Depression Inventory II.
671
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672

Table 2
Mean Scores and Standard Deviations of Primary and Secondary Outcome Measures at Pre-, Posttreatment, and Follow-up; Results of the Repeated Analyses of Variance;
and Effect Sizes of the Intention-to-Treat and Completer Samples

CT M (SD) ET M (SD) Interaction Hedges’s g ET-CT

Measures Pre Post 12-month Pre Post 12-month F p Post 12-month

Intention-to-treat sample (N ⫽ 68)

Primary outcome measure
H-YBOCS
Cognitive 11.06 (3.11) 6.57 (2.92) 5.37 (3.69) 10.88 (3.59) 6.18 (3.60) 4.91 (3.68) 0.05 .954 0.12 0.12
Behavioral 8.80 (4.08) 5.34 (3.90) 3.00 (4.03) 9.61 (4.25) 4.15 (3.89) 3.30 (3.84) 1.51 .226 0.31 ⫺0.08
Secondary outcome measures
IAS 71.04 (15.82) 53.18 (18.13) 47.39 (20.22) 72.26 (13.80) 53.63 (18.18) 47.39 (21.52) 0.05 .951 ⫺0.02 0.00
CABAH 32.90 (9.17) 25.30 (9.64) 22.27 (10.64) 33.88 (11.09) 23.46 (11.57) 22.16 (12.88) 0.95 .389 0.17 0.01
QSBH 31.72 (9.35) 24.38 (8.36) 22.73 (10.16) 34.71 (12.09) 23.88 (11.30) 21.97 (12.17) 2.06 .132 0.05 0.07
PHQ-15 8.75 (4.35) 6.14 (3.07) 5.40 (3.39) 7.47 (4.72) 5.40 (4.55) 5.18 (4.44) 0.77 .464 0.19 0.06
BAI 18.57 (12.04) 12.11 (7.65) 11.06 (8.62) 16.90 (12.53) 11.44 (12.46) 10.75 (11.78) 0.28 .754 0.07 0.03
BDI-II 13.14 (6.66) 7.09 (5.90) 6.69 (6.26) 11.49 (8.74) 7.58 (8.51) 6.82 (8.02) 1.32 .271 ⫺0.07 ⫺0.02

Completer sample (N ⫽ 60)

Primary outcome measure
H-YBOCS
Cognitive 10.87 (3.07) 6.20 (2.54) 4.80 (3.32) 10.90 (3.54) 6.03 (3.53) 4.59 (3.52) 0.03 .970 0.06 0.06
Behavioral 8.27 (4.05) 5.30 (3.73) 2.57 (3.72) 9.21 (4.35) 3.79 (3.68) 2.83 (3.51) 1.84 .163 0.41 ⫺0.07
Secondary outcome measures
IAS 67.84 (14.30) 48.31 (16.96) 39.88 (17.23) 69.38 (12.96) 44.85 (14.03) 36.06 (16.71) 0.73 .483 0.22 0.23
WECK, NENG, RICHTBERG, JAKOB, AND STANGIER

CABAH 30.38 (8.30) 23.23 (7.56) 18.81 (7.86) 32.70 (10.95) 19.27 (7.84) 17.78 (10.83) 2.69 .074 0.51 0.11
QSBH 30.55 (9.73) 23.56 (8.09) 21.14 (10.43) 33.48 (11.51) 19.45 (10.39) 16.50 (10.67) 4.91 .010 0.44 0.44
PHQ-15 7.68 (4.12) 5.41 (2.82) 4.33 (2.99) 6.66 (4.65) 3.69 (2.87) 3.46 (2.48) 0.35 .708 0.60 0.32
BAI 14.71 (9.26) 9.50 (6.06) 7.96 (7.14) 14.15 (10.03) 7.34 (8.38) 6.50 (5.95) 0.21 .812 0.30 0.22
BDI-II 12.92 (6.30) 6.04 (5.19) 5.46 (5.66) 10.17 (7.77) 5.00 (6.51) 3.70 (5.00) 0.36 .700 0.18 0.33
Note. CT ⫽ cognitive therapy; ET ⫽ exposure therapy; WL ⫽ wait list; ANCOVA ⫽ analyses of covariance; Pre ⫽ pretreatment; Post ⫽ posttreatment; 12-month ⫽ 12 month follow-up;
H-YBOCS ⫽ Yale–Brown Obsessive Compulsive Scale for Hypochondriasis; IAS ⫽ Illness Attitudes Scales; CABAH ⫽ Cognitions About Body and Health Questionnaire; QSBH ⫽ Questionnaire
for Assessing Safety Behavior in Hypochondriasis/Health Anxiety; PHQ-15 ⫽ Patients Health Questionnaire; BAI ⫽ Beck Anxiety Inventory; BDI-II ⫽ Beck Depression Inventory II.
 COGNITIVE THERAPY VERSUS EXPOSURE THERAPY
g ⫽ ⫺0.12; CABAH: Hedges’s g ⫽ ⫺0.07; QSBH: Hedges’s g ⫽
0.17; PHQ-15: Hedges’s g ⫽ ⫺0.12; BAI: Hedges’s g ⫽ 0.24;
BDI-II: Hedges’s g ⫽ 0.36) and at follow-up (IAS: Hedges’s
g ⫽ ⫺0.09; CABAH: Hedges’s g ⫽ ⫺0.32; QSBH: Hedges’s
g ⫽ ⫺0.06; PHQ-15: Hedges’s g ⫽ ⫺0.38; BAI: Hedges’s g ⫽
0.05; BDI-II: Hedges’s g ⫽ 0.50). No significant Time ⫻ Group
interactions were found.
Discussion
In the current study, ET and CT were shown to be highly
effective approaches for the treatment of patients with hypochon-
driasis. Both approaches led to significant improvements by re-
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ducing hypochondriacal cognitions and behaviors in comparison
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with the WL (Hypothesis 1). Depressive symptoms and bodily
complaints were reduced significantly by ET and CT, but we found
that anxiety symptoms were reduced significantly in ET and only
by trend in CT (Hypothesis 2). Treatment effects were maintained
in the CT and ET groups at the 12-month follow-up investigation
(Hypothesis 3). We found no differences between CT and ET in
the primary outcome measures. In the secondary outcome mea-
sures, we found a larger reduction in safety behaviors in the ET
group than in the CT group in the completer analyses (but not in
the ITT analyses; Hypothesis 4).
The current study addressed several limitations of previous
studies that investigated the efficacy of ET for hypochondriasis.
First, treatment integrity was evaluated; therapists’ adherence to
the treatment manuals was high and the level of competence was
satisfactory according to Shaw et al. (1999). Second, therapy
outcomes were assessed by an independent and blind diagnostician
with a reliable standardized interview, namely the H-YBOCS.
Third, ET included exposure in sensu, which can be considered an
important intervention for the treatment of health anxieties. Fourth,
ITT as well as completer analyses were conducted. Finally, the
follow-up period was expanded to 12 months.
In the current study, most effect sizes of the primary and
secondary outcome measures were large regarding the reduction of
hypochondriacal symptoms: CT versus WL (Hedges’s g ⫽
0.59 –1.18) and ET versus WL (Hedges’s g ⫽ 1.07–1.29). This is
in line with meta-analyses, which found a mean effect size of 0.86
and 0.95 in RCTs investigating psychotherapy for hypochondriasis
and health anxiety (Olatunji et al., 2014; Thomson & Page, 2007).
The large improvement in depressive and anxiety symptoms and
the moderate improvement in physical symptoms in the current
study are also consistent with the meta-analyses.
Olatunji et al. (2014) found only moderate effect sizes for CBT
in their follow-up investigations of the treatment of hypochondri-
asis and health anxiety (Hedges’s g ⫽ 0.34). In contrast with this
meta-analysis, we found large Pre-follow-up effect sizes for CT as
well as for ET for the primary outcome measures (Hedges’s g ⫽
1.43–1.67). One possible explanation for this differing finding
might be the implementation of booster sessions in the current
study. Booster sessions were suggested by Olatunji et al. as an
opportunity for sustaining treatment gains in follow-up investiga-
tions. Future studies should systematically investigate whether
booster sessions are able to ensure maintenance of therapy effects
in the treatment of health anxiety.
In contrast to the study by Visser and Bouman (2001), we found
no evidence that patients in CT showed larger improvements in
673
dysfunctional cognitions or depressive symptoms. Instead, we
found a trend that anxiety symptoms only improved with ET and
that safety behaviors improved more with ET than with CT. The
differences regarding the reduction of safety behavior might be
especially essential because experimental investigations have dem-
onstrated that safety behaviors (e.g., seeking reassurance, checking
your body in the mirror for moles) are an important risk factor for
the development and maintenance of health anxiety (e.g.,
Abramowitz & Moore, 2007; Olatunji, Etzel, Tomarken, Ciesliel-
ski, & Deacon, 2011). However, we found significant differences
only in the completer analyses but not in the ITT analyses, and
moreover, we found no differences between CT and ET in the
primary outcome measures. Therefore, results should be inter-
preted with caution.
When we only considered the subsample of patients with a
comorbid anxiety disorder, we found somewhat differing effect
sizes between CT and ET than in the whole sample. For example,
differences in the cognitive subscale became smaller and differ-
ences in the behavioral subscale of the H-YBOCS became larger.
However, these effect sizes should be considered cautiously be-
cause we found no significant Time ⫻ Group interactions and the
sample size was small (n ⫽ 23). Nonetheless, the different findings
for patients with comorbid anxiety disorders might be important
regarding a differential indication for CT and ET and should
therefore be tested in future studies.
A further interesting finding is that ET, which included no
formal cognitive restructuring, leads to such clear changes in
dysfunctional health-related cognitions. Similar results are re-
ported for the treatment of obsessive– compulsive disorder. There,
changes in cognitions occur in exposure therapy, even though
cognitive change was not the aim of the treatment (Solem, Håland,
Vogel, Hansen, & Wells, 2009). The clear efficacy of ET for
hypochondriasis also shows the close relationship between hypo-
chondriasis and anxiety disorders.
Considering the clinical implications of the current study, CT
and ET can be seen as effective treatment approaches for patients
with hypochondriasis. However, specific cognitive interventions
(e.g., cognitive restructuring) do not seem to be a necessary con-
dition for achieving cognitive changes. In our study, we generally
found higher effect sizes of ET than of CT, and a trend for
superiority of ET over CT for the reduction of anxiety and safety
behaviors was found. Moreover, effect sizes indicate that safety
behaviors (behavioral subscale of the H-YBOCS) seem to change
faster in ET than in CT (particularly when only including patients
with a comorbid anxiety disorder). Therefore, on the basis of the
current study, ET can be recommended as the preferential treat-
ment approach, especially when patients have a comorbid anxiety
disorder.
The current study has many strengths, but aspects that limit
generalizability of the findings should also be considered. First,
patients in the current study were seeking psychological treatment
for their health anxieties. However, patients with hypochondriasis
often seek medical treatment for their problems. Therefore, the
participants might have responded more than patients who remain
in medical settings would.
Second, 7.9% of the patients in CT and 10.8% in ET were
dropouts. Therefore, the treatment was not accepted by all
patients. However, in some previous RCTs, the dropout rate
was substantially higher, for example, 28.3% in the study by
 674 WECK, NENG, RICHTBERG, JAKOB, AND STANGIER
Visser and Bouman (2001) and 25.0% in the study by Greeven
et al. (2007). Therefore, acceptability of both of our approaches
can be considered to be satisfactory. Comparably low dropout
rates were also found in some other RCTs (e.g., Clark et al.,
1998; McManus, Surawy, Muse, Vazquez-Montes, & Williams,
2012) and underline the suitability of cognitive and behavioral
interventions for health anxiety.
Third, half of the participants (52%) had a comorbid disorder
and it can be questioned whether the findings can be general-
ized to patients without comorbid disorders. On the other hand,
such high rates of comorbidity are typical for patients with
hypochondriasis/health anxiety (e.g., Barsky, Wyshak, & Kler-
man, 1992; Sunderland et al., 2013). Therefore, it would be
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insufficient to only include patients without comorbid disor-
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ders, because that would be an unrepresentative selection of all
patients with health anxiety.
Finally, the quality of both treatments was high (i.e., specific
training for the therapists, regular supervision by experts, and
existence of a detailed treatment manual), which led to a high level
of treatment integrity. Therefore, the findings might not be gener-
alizable to routine mental healthcare, because it can be expected
that treatment standards are less high.
Since the beginning of the current study in 2010, the DSM
criteria for hypochondriasis have changed. In the DSM-5, hy-
pochondriasis is divided into two disorders (American Psychi-
atric Association, 2013). On the one hand, somatic symptom
disorder should be considered when one or more somatic symp-
toms are present, and on the other hand, illness anxiety disorder
should be considered when somatic symptoms are not present.
In the current study, patients with hypochondriasis had a
PHQ-15 score of 8.2 (SD ⫽ 4.7), which is comparable to
patients with an anxiety disorder (M ⫽ 9.7; SD ⫽ 5.8; Höfling
& Weck, 2013) but lower than in patients with medically
unexplained symptoms (M ⫽ 12.7; SD ⫽ 4.8; Konnopka et al.,
2013). Therefore, in the current study, somatic symptoms are
not of high relevance and findings can be seen as more relevant
for illness anxiety disorder than for somatic symptom disorder.
Moreover, the usefulness of splitting hypochondriasis into two
diagnoses in the DSM-5 has been criticized and it has been
questioned whether different therapeutic approaches for the
different disorders are necessary (e.g., Rief, 2013; Rief &
Martin, 2014). Therefore, future studies should show whether
different approaches are useful for the treatment of patients
(with health anxiety as their primary problem) with illness
anxiety disorder and somatic symptom disorder.
Furthermore, it can be questioned whether similar results
would be found for persons with health anxiety who do not meet
the diagnostic criteria for hypochondriasis. Empirical investi-
gations have shown that persons with a high level of health
anxiety and persons with the diagnosis of hypochondriasis were
found to be comparable in several characteristics (e.g., level of
disturbance, persistence of health anxiety, frequency of health-
care use; Fink et al., 2010). Moreover, differences between
health anxiety and hypochondriasis are quantitative rather than
qualitative (Ferguson, 2009; Longley et al., 2010). Therefore, it
can be expected that comparable treatment results would
emerge for persons with elevated health anxiety.
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Received August 6, 2014
Revision received October 9, 2014
Accepted October 26, 2014 䡲