بررسی آزمایشی فرآیندهای تغییر در درمان مبتنی بر پذیرش و تعهد مبتنی بر گروه برای اضطراب سلامتی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|35431||2014||6 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Contextual Behavioral Science, Volume 3, Issue 3, July 2014, Pages 189–195
Background Health anxiety or hypochondriasis is a disabling and persistent disorder with a high prevalence in primary care, and insufficient treatment opportunities and knowledge of treatment processes. Acceptance and Commitment Therapy (ACT) is a third-wave behavioral therapy, which has shown positive treatment effects in a variety of mental disorders. ACT is proposed to work through the process of ‘psychological flexibility’, but no studies have yet examined possible processes of change in an ACT-based treatment of health anxiety. Aim The pilot study investigated whether changes in ‘psychological flexibility’ and ‘mindfulness’ mediated treatment outcome in health anxiety symptoms. Methods 34 Danish patients with severe health anxiety were allocated to 10 sessions of group-based ACT. The patients completed self-report questionnaires at baseline, at end of treatment and at 6-month follow-up, measuring health anxiety symptoms (Whiteley Index), psychological flexibility (AAQ-II) and mindfulness (FFMQ). Results Paired t-tests showed that psychological flexibility and mindfulness increased significantly during treatment (effect sizes ranged from SRM=.55–.76, p<.05). Regression analysis and Likelihood Ratio Tests showed that in particular psychological flexibility was significantly associated with the previously reported 49% reduction in health anxiety symptoms at 6-month followup. Conclusions Findings from the uncontrolled study indicated that the decrease in health anxiety symptoms at 6-month follow-up was associated with the change in psychological flexibility and mindfulness during treatment. These findings support the processes of change proposed in ACT.
Health anxiety (hypochondriasis) or Illness Anxiety Disorder (Diagnostic and Statistical Manual of Mental Disorders; 5th ed., or DSM-5; APA,2013) is characterized by preoccupation with fear of having a serious illness, which interferes with daily functions and persists despite medical reassurance. Severe health anxiety is a disabling and persistent disorder ( Fink et al., 2010 and Noyes et al., 1994) with a prevalence of .8–9.5% in primary care ( Creed and Barsky, 2004, Fink et al., 2004 and Gureje et al., 1997), and a lifetime prevalence of 5.7% in the general population ( Sunderland, Newby, & Andrews, 2013). Despite the high prevalence, health anxiety is rarely diagnosed and has been considered a chronic disease with poor treatment outcomes ( Barsky & Ahern, 2004). In addition to the suffering health anxiety inflicts on the patients, the disorder is costly in terms of the patients׳ extensive use of health care services ( Barsky et al., 2001 and Fink et al., 2010) and occupational disability ( Mykletun et al., 2009). Health anxiety patients have been found to prefer psychotherapeutic treatments rather than drug treatments (Walker, Vincent, Furere, Cox, & Kjernisted, 1999), but research regarding psychological treatment effects on health anxiety is limited. At this point cognitive-behavioral therapy (CBT) has shown the best treatment effects according to the latest review (Thomson & Page, 2007). Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 2012) is a third-wave cognitive-behavioral therapy which has shown similar treatment effects as CBT (Levin and Hayes, 2009 and Powers et al., 2009). ACT is considered a transdiagnostic treatment approach, and has shown effect on a variety of disorders with moderate research support for depression, mixed anxiety, obsessive-compulsive disorder and psychosis, and strong research support for chronic pain (American Psychological Association, 2013). This open trial is the first to investigate ACT for health anxiety. The uncontrolled results on the outcome measures have been analyzed and reported elsewhere, suggesting that group-based ACT may be a feasible treatment for health anxiety (Eilenberg, Kronstrand, Fink, & Frostholm, 2013). Additional data from the same study are further investigated in this article. Attention to physical health, and even a certain degree of concern about it, is adaptive to reduce the risk of overlooking signs of illness. But the risk of getting a serious illness and eventually dying is part of the human condition and cannot be avoided. Therefore, the treatment aimed to increase patients׳ ability to accept thoughts and feelings regarding illness and change behavioral patterns tied to avoiding aversive private events (e.g., repeatedly seeking medical reassurance, or avoiding contact to sick relatives). ‘Psychological flexibility’ is the ability to freely change behavior in contexts of different demands and values, which include the capacity to stay in contact with unpleasant thoughts, feelings and bodily sensations that normally cause experiential avoidance (Hayes et al., 2012). Experiential avoidance is considered a core mechanism in psychopathology (Boulanger et al., 2010 and Chawla and Ostafin, 2007), and enhanced psychological flexibility is hypothesized to reduce experiential avoidance through the training of mindfulness and acceptance processes and behavior change processes (Ciarrochi, Bilich, & Godsel, 2010). Research has repeatedly shown that ACT increases psychological flexibility across a wide range of psychological disorders and health conditions (Ruiz, 2010), and that psychological flexibility is associated with treatment outcomes. The term ‘mindfulness’ originates from the Pali word Sati in the Buddhist scriptures, and is part of a 2500 year old eastern meditation practice ( Baer, 2003). Mindfulness is usually defined to include bringing one׳s complete attention to the experiences occurring in the present moment, in a non-judgmental or accepting way ( Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006, p. 27). In recent decades mindfulness has been adapted for secular use, and integrated into several psychological interventions to alleviate symptoms and improve mental health ( Khoury et al., 2013). Mindfulness-Based Cognitive Therapy (MBCT) ( Segal, Williams, & Teasdale, 2002) is another psychological intervention where meditation is practiced up to 45 min each day. A randomized clinical trial of MBCT for health anxiety ( McManus, Surawy, Muse, Vazquez-Montes & Williams, 2012), found that mindfulness mediated reductions in health anxiety symptoms, suggesting that the ‘mindful’ ability to bring attention to the present moment in a non-judgmental and accepting way may be a process of change. Psychological flexibility and mindfulness are interrelated but different processes (Baer et al., 2006 and Hayes et al., 2012). The model of psychological flexibility involves six core processes: acceptance, defusion, contact to the present moment, self as context, values and committed action – all influencing the ability to choose actions freely, which is the core function of psychological flexibility. Mindfulness, in ACT terminology, is best understood as contact to the present moment where attention is shifted to the stimuli here and now internally (e.g., thoughts, feelings, and sensations) and externally (e.g., sounds and sights), instead of being inattentive or caught up in mental chatter. Mindfulness is thereby the ability to bring attention to the present moment, and differs from psychological flexibility which is the ability to align current behaviors with long-term goals and values. Both mindfulness and psychological flexibility emphasize acceptance as a core feature which is why an overlap between the processes exists. Research in mediation has received growing attention in the psychotherapeutic literature (Kazdin, 2007). Several studies have investigated mediation in ACT, and the most supported process of change is psychological flexibility (Bond et al., 2011 and Ruiz, 2012). The following studies have shown that psychological flexibility mediate treatment outcomes and that changes in the mediator occurred before symptom reduction, e.g. social phobia (Dalrymple & Herbert, 2007), tinnitus (Hesser, Westin, Hayes, & Andersson, 2009), and PTSD (Thompson & Waltz, 2010). Investigation and a better understanding of processes that lead to therapeutic change may help to specialize treatments and ultimately make treatments more effective. The aims of this study were (1) to examine whether patients would report higher levels of psychological flexibility and higher levels of mindfulness following participation in group-based ACT, and (2) to examine whether changes in psychological flexibility and mindfulness would mediate treatment outcomes in health anxiety symptoms. The intervention being ACT and not a strictly mindfulness-based treatment, we expected in accordance with the theoretical outline of ACT that psychological flexibility would be a stronger mediator of outcome than mindfulness.
نتیجه گیری انگلیسی
3.1. Changes on study variables Results regarding the primary outcome measure WI-7 have been presented elsewhere (Eilenberg et al., 2013) and are reported here with permission from the authors. Overall, patients reported statistically significant reductions in health anxiety symptoms after treatment with mean scores from baseline (M=67.2, SD=26.8) to end of treatment (M=40.6, SD=26.0), t=6.6, p<.001 and 6-month follow-up (M=34.5, SD=26.9), t=7.1, p<.001 compared to baseline scores ( Table 1). All in all, a 40% symptom reduction and large effect size at end of treatment SRM=1.20 CI(.74;1.66) and a 49% symptom reduction and large effect size at 6-month follow-up, SRM=1.32, CI(.82;1.82). Table 1. Outcome and process measures. Mean scores and effect sizes at baseline, at end of treatment, and at 6-month follow-up. Measures Mean (SD) t SRM (CI) Change % WI-7 (0–100)a Baseline 67.2 (26.8) End of treatment 40.6 (26.0) 6.65 (p<.001) 1.20 (.74;1.66) −40 6-month follow-up 34.5 (26.9) 7.10 (p<.001) 1.32 (.82;1.82) −49 AAQ (0–100) Baseline 44.8 (19.5) End of treatment 57.0 (23.1) −3.30 (p=.003) .76 (.35;1.17) 27 6-month follow-up 62.2 (23.8) −4.40 (p<.001) 1.08 (.61;1.55) 39 FFMQ (0–100) Baseline 50.3 (8.1) End of treatment 55.8 (11.6) −2.54 (p=.018) .55 (.16;.94) 11 6-month follow-up 61.9 (15.0) −4.11 (p<.001) .88 (.45;1.31) 23 Observe (0–20.05) Baseline 9.5 (3.7) End of treatment 9.5 (4.4) .08 (p=.940) 0 (−.34;.35) 0 6-month follow-up 9.4 (5.4) .64 (p=.530) 0 (−.32;.37) 0 Describe (0–20.05) Baseline 13.4 (4.3) End of treatment 14.1 (3.7) −1.19 (p=.245) .30 (−.05;.65) 5 6-month follow-up 15.9 (3.5) −4.69 (p<.001) .93 (.51;1.35) 19 Actaware (0–20.05) Baseline 10.9 (4.3) End of treatment 12.0 (4.2) −1.52 (p=.142) .34 (−.02;.69) 10 6-month follow-up 13.1 (5.1) −2.24 (p=.034) .49 (.12;.86) 20 Non-judge (0–20.05) Baseline 10.5(4.2) End of treatment 12.1 (4.7) −1.78 (p=.087) .39 (.03;.75) 15 6-month follow-up 14.4 (4.8) −3.93 (p<.001) .81 (.41;1.22) 37 Non-react (0–18) Baseline 4.7 (2.3) End of treatment 6.4 (3.1) −2.93 (p=.007) .57 (.19;.94) 36 6-month follow-up 7.3 (3.7) −3.49 (p=.002) .73 (.34;1.13) 55 WI-7=Whiteley Index 7-item version; AAQ=Acceptance and Action Questionnaire; FFMQ=Five Facet Mindfulness Questionnaire; Actaware=Act with awareness; SD=Standard Deviation; SMR=Standardized Response Mean; CI=Confidence interval; and % change=((T1-Tn)/T1)×100. p-Values are calculated by paired t-tests comparing either end of treatment or 6-month follow-up scores to baseline. a Results are reported with permission from the authors of Eilenberg et al. (2013). Table options Results regarding the process measures showed the following (Table 1); Patients reported a significant increase in psychological flexibility (AAQ) from baseline (M=44.8, SD=19.5) to end of treatment (M=57.0, SD=23.1), t=−3.3, p=.003, with a 27% increase and a moderate effect size SRM=.76, CI(.35;1.17). The effect was sustained and further increased at 6-month follow-up (M=62.2, SD=23.8), t=−4.4, p<.001. All in all, from baseline to 6-month follow-up, a 39% increase in psychological flexibility with a large effect size SRM=1.08, CI(.61;1.55). Similar results were found for the entire 39-item mindfulness measure (FFMQ), where the patients reported a significant increase from baseline (M=50.3, SD=8.1) to end of treatment (M=55.8, SD=11.6), t=−2.5, p=.018, with an 11% increase and a moderate effect size SRM=.55, CI(.16;.94). The effect was sustained at 6-month follow-up (M=61.9, SD=15.0), t=−4.1, p<.001. All in all from baseline to 6-month follow-up, a 23% increase in mindfulness with a large effect size SRM=.88, CI(.45;1.31). Significant changes were found on all sub-scales of the FFMQ, except the subscale ‘observe’ ( Table 1). Strong correlations were found between AAQ and both the entire FFMQ measure and the subscales ( Table 2). Table 2. Correlation matrix between process variables at end of treatment. AAQ FFMQ Observe Describe Actaware Non-jugde Non-react AAQ 1 – – – – – – FFMQ .67 (p<.001) 1 – – – – – Observe −.43 (p=.019) .14 (p=.482) 1 – – – – Describe .42 (p=.024) .74 (p<.001) .05 (p=.798) 1 – – – Actaware .70 (p<.001) .55 (p=.002) −.39 (p=.037) .23 (p=.236) 1 – – Non-jugde .63 (p<.001) .72 (p<.001) −.36 (p=.057) .51 (p=.005) .45 (p=.015) 1 – Non-react .60 (p<.001) .72 (p<.001) .09 (p=.646) .37 (p=.048) .27 (p=.149) .39 (p=.036) 1 AAQ=Acceptance and Action Questionnaire; FFMQ=Five Facet Mindfulness Questionnaire; and Actaware=Act with awareness. Table options 3.2. Mediation analyses Table 3 displays models of mediation investigating the mediation effect of treatment changes in psychological flexibility and mindfulness on patients׳ health anxiety symptoms at 6-month follow-up. Table 3. Models of mediation. R2 B CI p Potential mediators of Health anxiety (Health anxiety) symptoms at 6-month follow-up Model 1: Health anxiety symptoms at 6-month Follow-up (dv) .34 1. Health anxiety symptoms at baseline (iv) .57 .33; .80 <.001 Model 1.a: Health anxiety symptoms at 6-month Follow-up (dv) .54 1. Health anxiety symptoms at baseline (iv) .47 .22; .72 <.001 2. Pre-post treatment changes in Psychological flexibility (iv) −.71 −1.09; −.33 <.001 Model 1.b: Health anxiety symptoms at 6-month Follow-up (dv) .57 1. Health anxiety symptoms at baseline (iv) .56 .32; .79 <.001 2. Pre-post treatment changes in Mindfulness (iv) −.1.17 −1.84; −.49 .001 Reversed mediation models of Psychological flexibility and Mindfulness at 6-month follow-up Model 2: Psychological flexibility at 6-month Follow-up (dv) .42 1. Psychological flexibility at baseline (iv) .83 .38; 1.27 <.001 Model 2.a: Psychological flexibility at 6-month Follow-up (dv) .53 1. Psychological flexibility at baseline (iv) .92 .48; 1.37 <.001 2. Pre-post treatment changes in Health anxiety symptoms (iv) −.22 −.55; .10 .184 Model 3: Mindfulness at 6-month Follow-up (dv) .23 1. Mindfulness at baseline (iv) .81 .31; 1.31 .001 Model 3.a: Mindfulness at 6-month Follow-up (dv) .40 1. Mindfulness at baseline (iv) .91 .33; 1.49 .002 2. Pre-post treatment changes in Health anxiety symptoms (iv) −.28 −.51; −.04 .021 Linear regression analyses where the dependent variable (dv) is outcome variable, and the independent variables (iv) are explaining variables. R2=Coefficient of determination; B=Unstandardized regression coefficient; and CI=95% Confidence interval (Bootstap). Table options According to Model 1, the patients׳ level of health anxiety symptoms before treatment accounted for 34% of the variance in health anxiety symptoms at 6-month follow-up (R2=.34). The coefficient corresponding to the level of health anxiety symptoms at baseline was .57 (.33;.80), p<.001. According to Model 1.a, changes in psychological flexibility during treatment and baseline health anxiety symptoms accounted for 54% of the variance in health anxiety symptoms at 6-month follow-up (R2=.54). The coefficient corresponding to the change in psychological flexibility during treatment was −.71 (−1.09;−.33), p<.001. A Likelihood Ratio Test compared the fit between model 1 and 1.a, which showed that psychological flexibility is a significant variable in predicting health anxiety symptoms at 6-month follow-up (LR=8.49, p=.004). According to Model 1.b, patients׳ changes in mindfulness and baseline health anxiety symptoms explained 57% of the variance in health anxiety symptoms at 6-month follow-up (R2=.57). The coefficient corresponding to the changes in mindfulness during treatment was −1.17 (−1.84;−.49), p=.001. According to the Likelihood Ratio Test, mindfulness was a significant variable in predicting health anxiety symptoms at 6-month follow-up (LR=8.09, p=.005). Table 3 also presents the reversed linear regression analyses, investigating either psychological flexibility or mindfulness as the dependent variable, and changes in health anxiety symptoms during treatment as the mediator in the model. Model 2.a showed that changes in health anxiety symptoms during treatment did not have a significant effect on psychological flexibility at 6-month follow-up with a non-significant coefficient at −.22 (−.55;.10), p=.184. A Likelihood Ratio Test supports this finding comparing the fit of model 2 and 2.a (LR=2.11, p=.146). Model 3.a showed that change in health anxiety symptoms during treatment could be a possible mediator for mindfulness at 6-month follow-up, with a coefficient corresponding to the changes in health anxiety symptoms during treatment −.28 (−.51;.−04), p=.021 supported by a Likelihood Ratio Test (LR=5.30, p=.021).