Group Psychotherapy of Dysfunctional Fear of Progression in Patients with Chronic Arthritis or Cancer

Article (PDF Available)inPsychotherapy and Psychosomatics 79(1):31-8 · January 2010with124 Reads
DOI: 10.1159/000254903 · Source: PubMed
This study investigated the effectiveness of brief psychotherapeutic group interventions in reducing dysfunctional fear of disease progression (FoP). The interventions comprised either cognitive-behavioral group therapy or supportive-experiential group therapy. We tested whether these generic interventions would prove effective in different illness types. Chronic arthritis in- patients (n = 174) and cancer in-patients (n = 174), respectively, were randomized to receive one of the two interventions. The patients provided data before intervention, at discharge, and at 3 and 12 months of follow-up. FoP was the primary outcome, secondary outcomes were anxiety, depression and quality of life. A treatment-as-usual control group provided data on the primary outcome. Patients with chronic arthritis indicated higher levels of FoP than cancer patients. The results revealed that, compared with no specialized intervention, both group therapies were effective in reducing dysfunctional FoP, but only among cancer patients. The effect sizes were 0.54 (cognitive-behavioral therapy) and 0.50 (supportive experiential therapy). The interventions were not differently effective in reducing the secondary outcomes. Dysfunctional FoP can be effectively targeted with brief group interventions. Psychotherapeutic interventions for reducing FoP should focus on specific illness characteristics.


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Regular Article
Psychother Psychosom 2010;79:31–38
DOI: 10.1159/000254903
Group Psychotherapy of Dysfunctional
Fear of Progression in Patients with
Chronic Arthritis or Cancer
Peter Herschbach
Petra Berg
Sabine Waadt
Gabriele Duran
Ursula Engst-Hastreiter
Gerhard Henrich
Katrin Book
Andreas Dinkel
Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische
Universität München,
Institute for Therapy Research, IFT-Gesundheitsförderung, München , and
Rheumatology Rehabilitation Center, Bad Aibling , Germany
cancer patients. The effect sizes were 0.54 (cognitive-behav-
ioral therapy) and 0.50 (supportive experiential therapy).
The interventions were not differently effective in reducing
the secondary outcomes. Conclusions: Dysfunctional FoP
can be effectively targeted with brief group interventions.
Psychotherapeutic interventions for reducing FoP should fo-
cus on specific illness characteristics.
Copyright © 2009 S. Karger AG, Basel
Research has shown that many medical patients suffer
from comorbid mental illness
[1– 6] . However, some re-
searchers and clinicians pointed out limitations of the
psychiatric model in medical illness
[7–9] . As a conse-
quence, alternative taxonomies were developed
[8, 10, 11] .
Fears and concerns of medical patients are, mostly, real-
istic, although they might be exaggerated beyond the ac-
tual threat. As such, they differ from typical psycho-
pathological fears
[ 12 ]. Many of these fears arise from
common adaptive tasks that medical patients are facing
[1315] .
In our work, we elaborated on fear of disease progres-
sion (FoP). Based on results on recurrence fears
[16 –18] ,
Key Words
Fear of progression Group psychotherapy Randomized
controlled trial Rheumatoid arthritis Cancer Chronic
Background: This study investigated the effectiveness of
brief psychotherapeutic group interventions in reducing
dysfunctional fear of disease progression (FoP). The inter-
ventions comprised either cognitive-behavioral group ther-
apy or supportive-experiential group therapy. We tested
whether these generic interventions would prove effective
in different illness types. Methods: Chronic arthritis in-
patients (n = 174) and cancer in-patients (n = 174), respec-
tively, were randomized to receive one of the two interven-
tions. The patients provided data before intervention, at
discharge, and at 3 and 12 months of follow-up. FoP was the
primary outcome, secondary outcomes were anxiety, de-
pression and quality of life. A treatment-as-usual control
group provided data on the primary outcome. Results: Pa-
tients with chronic arthritis indicated higher levels of FoP
than cancer patients. The results revealed that, compared
with no specialized intervention, both group therapies were
effective in reducing dysfunctional FoP, but only among
Received: August 6, 2008
Accepted after revision: April 3, 2009
Published online: November 4, 2009
Peter Herschbach
Department of Psychosomatic Medicine and Psychotherapy
Division of Psychosocial Oncology, Klinikum rechts der Isar
Technische Universität München, Langerstrasse 3, DE81675 München (Germany)
Tel. +49 89 4140 4318, Fax +49 89 4140 4845, E-Mail
© 2009 S. Karger AG, Basel
Accessible online at:
Herschbach /Berg /Waadt /Duran /
/Henrich /Book /Dinkel
Psychother Psychosom 2010;79:31–38
we explored FoP in different illnesses [19] . We define FoP
as a reactive, nonneurotic fear patients are fully aware of.
It is based on the experience of a chronic, life-threatening
or incapacitating illness. High levels of FoP cause suffer-
ing and reduce the quality of life (QoL)
[7] . Thus, there is
need for effective treatments of dysfunctional FoP. Most
studies investigating effects of psychotherapeutic inter-
ventions with medical patients focused on emotional dis-
tress and QoL. Group therapies based on cognitive-be-
havioral principles predominate and seem to be most ef-
[2025] . However, such studies did not address
FoP. Stress management interventions typically focus on
problem-solving strategies in general or in regard to
medical procedures
[2628] . Interventions focusing on
existential issues may target fears and concerns
[29, 30] ,
but they are not based on the concept of FoP. Further-
more, most investigations focus on a single illness, impli-
cating that unique aspects predominate. However, differ-
ent chronic illnesses share many psychosocial character-
[13, 14, 31] , and the prevalence rates of mental
disorders are comparable between different diseases
. Although there are also differences in consequences
[3235] , the lack of generic interventions is striking [see
36 for an exception].
In this study, we investigated the effects of generic psy-
chotherapeutic interventions on dysfunctional FoP. We
assumed that a cognitive-behavioral group therapy (CBT)
would be more beneficial in reducing FoP than a client-
centered, supportive-experiential group therapy (SET).
We examined whether these interventions would show
the same effects across different diseases. Finally, we
asked whether the 2 group therapies would also lead to a
reduction in anxiety and depression and an improvement
in QoL, which are the secondary outcomes.
M e t h o d s
Study Design
This was a multicenter, longitudinal (partially) randomized
controlled study. Arthritis patients came from 1 rehabilitation
clinic, cancer patients were approached in 2 rehabilitation clinics.
The patients were randomized into 2 interventions. The control
group received treatment as usual. The study protocol received
approval from the local ethics committee. The sample size was
determined a priori. We assumed a rather small effect between
the 2 different interventions, 80% power and 20% attrition. This
resulted in a desired sample size of 164 patients.
P a r t i c i p a n t s
To be eligible for the study, patients had to be at least 18 years
old and had to suffer from dysfunctional FoP, i.e. they had to score
above a predefined cutoff (see section ‘Caseness’). Of 548 arthritis
patients screened, 252 were eligible; 174 (69.0%) agreed to par-
ticipate and were randomized. Additionally, 84 patients were
sampled into the control group. The sociodemographic and ill-
ness-related characteristics are given in tables 1 and 2 . The arthri-
tis patients did not differ in sociodemographic characteristics
across the 3 groups. However, the proportion of patients who re-
ceived surgery was lower in the CBT group. Of 457 cancer patients
screened, 210 were eligible. Of those, 174 (82.8%) agreed to par-
ticipate and were randomized. In addition, 91 patients were re-
cruited for the control group (see tables 1 and 2 ). The only sig-
nificant difference between the groups was the proportion of pa-
tients receiving surgery being lower in the control group.
With regard to the 2 diagnostic groups, the proportion of fe-
male patients was lower in the arthritis sample [
(1) = 4.85, p !
0.05]. The arthritis patients were younger [t(521) = –8.07, p !
0.001], less often retired [
(5) = 96.56, p ! 0.001] and had a longer
duration of disease [t(190) = 9.31, p ! 0.001].
Treatment Conditions
The patients in the intervention conditions received 4 sessions
of group psychotherapy, each lasting 90 min. The CBT interven-
Table 1. Sociodemographic characteristics across diagnosis
(chronic arthritis: n = 258; cancer: n = 265)
Arthritis Pa-
Cancer Pa-
Mean age 8 SD, years 46.789.5
Sex 258 265
Female 194 (75.2) 220 (83.0)
Living with partner 253 262
Yes 204 (80.6) 204 (77.9)
Educational level 258 263
Elementary school 90 (34.9) 96 (36.5)
Secondary school/
junior high 81 (31.4) 90 (34.2)
High school 80 (31.0) 68 (25.9)
Other 7 (2.7) 9 (3.4)
Employment status 255 256
Full-time 113 (44.3) 83 (32.4)
Less than full-time 81 (31.8) 51 (19.9)
Unemployed 35 (13.7) 10 (3.9)
Homemaker 6 (2.4) 25 (9.8)
Retired 3 (1.2) 68 (26.6)
Other 17 (6.7) 19 (7.4)
Subjective economic situation 253 260
Very good 10 (4.0) 14 (5.4)
Good 73 (28.9) 73 (28.1)
Satisfactory 121 (47.8) 123 (47.3)
Not very good 30 (11.9) 40 (15.4)
Poor 19 (7.5) 10 (3.8)
Figures are numbers of patients with percentages in parenthe-
ses unless otherwise indicated. Data may not sum to full sample
size due to missing data.
Psychotherapy of Dysfunctional Fear of
Psychother Psychosom 2010;79:31–38
tion was manualized with regard to structure and content, topics
and interventions were predefined. The SET intervention was
also manualized with regard to structure but less prescriptive re-
garding the content.
General characteristics of the CBT group were directiveness
and specificity, both aiming at confronting patients with their
fears and learning to cope with them. The goal was to learn to
manage FoP in order not to become overwhelmed by fear in daily
life. Specific goals were to strengthen the patients’ self-awareness
regarding the elicitation and experience of fear, to confront wor-
rying thoughts and to decatastrophize. Educational elements and
homework assignments’ were included.
The SET group intervention was based on a client-centered
concept and characterized by nondirectiveness and unspecificity.
The main therapeutic goals were emotional expression, mutual
support and reassurance, and social comparison. The interven-
tion did not focus on the management of FoP. In each session, the
participants decided which topic they would like to discuss. Typ-
ically, it was one of the following themes: subjective illness repre-
sentations and coping with illness, spirituality and life goals, so-
cial network and intimate relationships, and autonomy.
Originally, the SET intervention was conceptualized as the
control condition. However, to exclude that improvement in FoP
was related to overall improvement through the rehabilitation
program, a treatment-as-usual control group was sampled.
Therapists and Therapist Adherence
The groups were led by psychotherapists who had at least 3
years of clinical experience and/or who had accomplished or were
in the final phase of their training. They were trained by 2 of the
authors (S.W., G.D.). All sessions were supervised. Meetings were
held regularly to ensure treatment integrity, using audiotapes to
discuss difficult group situations.
Assessment and Measures
The patients from the intervention groups provided data on
all measures prior to the initial session (T1), before discharge
(T2), as well as 3 months (T3) and 12 months (T4) after discharge.
The patients from the control condition only provided data on the
primary outcome at T1, T2 and T4.
FoP was assessed with the Fear of Progression Questionnaire
[19] . It comprises 43 items relating to 5 dimensions: af-
fective reactions, partnership/family, occupation, loss of autono-
my and coping with anxiety. We used the total score, i.e. the sum
of the subscales’ mean scores excluding the coping scale. The in-
ternal consistency in the current sample was = 0.91. The 12-item
short form, FoP-Q-SF, comprises items pertaining to 4 of the 5
dimensions (excluding coping). Cronbach’s of this unidimen-
sional scale is 0.87
[37] . We used the FoP-Q-SF as screening device
in the current study.
Anxiety and depression were assessed with the German ver-
sion of the Hospital Anxiety and Depression Scale
[38] . The inter-
nal consistency in the study sample was = 0.81 for anxiety and
= 0.85 for depression.
We used the German version of the SF-12 to measure health-
related QoL (HRQoL)
[39] . Two components, physical and men-
tal, are computed with scores ranging from 0 (worst) to 100 (best).
The patients reported on their HRQoL during the past 2 weeks.
Life satisfaction was measured with the Questions on Life Sat-
isfaction (FLZ
) [40] . This measure contains 2 modules, of which
only ‘general life satisfaction’ (LS) was used. The participants rat-
ed their LS during the past 4 weeks, with increasing scores indi-
cating higher LS. The reliability of the LS module in this sample
was = 0.70.
C a s e n e s s
The cutoff for dysfunctional FoP was derived in an investiga-
tion conducted before this study, with 130 arthritis and 150 can-
cer in-patients. These patients filled in the FoP-Q-SF and indi-
cated whether they felt in need of treatment for FoP. We followed
the conventional strategy of using the median score. Next, we
stratified the sample according to their self-reported treatment
need. Thirty-eight percent of the arthritis patients and 36% of the
cancer patients scored above the median and felt in need of treat-
ment. About 10% in both groups scored above the median and did
not express a need for treatment, and about 30% scored below the
median but expressed treatment need. These results qualified the
median as a pragmatic cutoff. The consequence of this approach
Table 2. Illness-related characteristics across diagnoses (chronic
arthritis: n = 258; cancer: n = 265)
Chronic arthritis
Mean illness duration 8 SD (n = 172), months 103.38115.4
Diagnosis (n = 258)
Chronic polyarthritis 91 (35.3)
Spondylitis ankylosans 38 (14.7)
Degenerative rheumatic disease 97 (37.6)
Other 99 (38.4)
Affected joints (n = 224)
1–3 64 (28.6)
4–6 68 (30.4)
7–9 31 (13.8)
>9 61 (27.2)
Other organs affected (n = 243) 71 (29.2)
Treatment: surgery (n = 252) 61 (24.2)
Mean illness duration 8 SD (n = 220), months 19.2830.6
Diagnosis (n = 263)
Breast cancer 155 (58.9)
Colon cancer 21 (8.0)
Bladder/prostate cancer 25 (9.5)
Gynecological cancer 24 (9.1)
Other 38 (14.4)
Treatment (n = 263)
Surgery 242 (92.4)
Radiotherapy 155 (59.2)
Chemotherapy 167 (63.7)
Disease status (n = 236)
No activity 185 (78.4)
Recurrence 20 (8.5)
Metastases 31 (13.1)
Figures are numbers of patients with percentages in parenthe-
ses unless otherwise indicated. Data may not sum to full sample
size due to missing data.
Multiple responses.
Herschbach /Berg /Waadt /Duran /
/Henrich /Book /Dinkel
Psychother Psychosom 2010;79:31–38
was the use of different median scores. Thus, the cutoff scores
(median, Md) for this intervention study were Md = 38 for the
arthritis patients and Md = 34 for the cancer patients.
P r o c e d u r e
From August 2002 until December 2003, each patient admit-
ted to 1 of the 3 participating rehabilitation clinics was invited to
take part in an information session. The patients were asked to f ill
in the FoP-Q-SF. Those who scored above the cutoff and were
willing to participate provided informed consent and were ran-
domized. The patients received a code, which was sent for exter-
nal randomization, using random numbers. Randomization was
stratified by diagnosis, and the patients were blind with regard to
group assignment. No patient changed the assigned group. The
patients from the intervention groups received booster phone
calls 6 and 9 months after discharge. The control group was sam-
pled in the same clinics 1 year after the completion of the inter-
ventions using the same eligibility criteria. The patients’ flow
through the study is detailed in figure 1 .
Statistical Analyses
We used an intention-to-treat approach and included all pa-
tients who provided baseline scores. Missing data were imputed
(SPSS expectation maximation algorithm). Longitudinal changes
in FoP were investigated with a repeated-measures ANOVA. We
adopted a 3 (group: CBT, SET, control) ! 3 (time: T1, T2, T4) !
2 (diagnosis: arthritis vs. cancer) approach with time as repeated
measure. As the patients from the control group did not provide
data on secondary outcomes, we performed a 2 (group) ! 4 (T1,
T2, T3, T4) ! 2 (diagnosis) repeated-measures ANOVA. We com-
puted effect sizes for the change between pretherapy assessment
and 12-month outcomes using the pooled variance of the com-
plete sample.
Assessed for eligibility,
n = 1,005
Eligible, n = 462
Randomized, n = 348
T1 assessment, n = 170
Session 1, n = 172
Session 2, n = 162
Session 3, n = 157
Session 4, n = 147
T2 assessment, n = 168
T3 assessment, n = 145
Booster 1, n = 141
Booster 2, n = 116
T4 assessment, n = 137
Therapy attendance
Allocated to CBT, n = 178
Allocated to SET, n = 170
T1 assessment, n = 164
Session 1, n = 167
Session 2, n = 154
Session 3, n = 138
Session 4, n = 119
T2 assessment, n = 148
T3 assessment, n = 137
Booster 1, n = 135
Booster 2, n = 102
T4 assessment, n = 115
Allocated to Control, n = 175
T1 assessment, n = 172
T2 assessment, n = 171
T4 assessment, n = 121
Fig. 1. Flow of the participants through
the study.
Psychotherapy of Dysfunctional Fear of
Psychother Psychosom 2010;79:31–38
R e s u l t s
Preliminary Analysis
At baseline, the 2 intervention groups and the control
group did not differ in the primary outcome, and the in-
tervention groups did not differ in the secondary out-
comes, in either one diagnostic group (data not shown).
Next, we studied differences between the complete ar-
thritis and cancer samples. Patients with chronic arthri-
tis had higher FoP scores [M = 12.7, SD = 2.5 vs. M = 11.4,
SD = 2.5; t(504) = 5.92, p ! 0.001], and they expressed
lower physical HRQoL [M = 35.3, SD = 8.2 vs. M = 39.0,
SD = 8.3; t(326) = 4.10, p ! 0.001] at baseline.
Attrition analysis revealed few significant results. In
the arthritis group, not living with a partner [
(1) = 4.18,
p ! 0.05] and educational level [
(3) = 8.11, p ! 0.05], i.e.
less than high school, were associated with dropout. Fur-
thermore, the study group affected attrition [
(2) = 9.11,
p ! 0.05]. Fewer patients from the CBT group than from
the SET group and the control condition dropped out of
the study. In the sample of cancer patients, those being
older [t(263) = 2.67, p ! 0.01] and being retired [
(5) =
14.90, p ! 0.05] were more likely to withdraw. In addition,
experiencing recurrence [
(2) = 8.20, p ! 0.05] and low-
er physical HRQoL [t(160) = 2.21, p ! 0.05] were associ-
ated with dropping out of the study.
Longitudinal Analysis
The analysis revealed 2 significant main effects and a
significant 3-way interaction with regard to the primary
outcome ( table 3 ). The results showed that FoP decreased
over time and that diagnosis had an influence on FoP.
These main effects should be interpreted in light of the
interaction between group, time and diagnosis. Thus,
both interventions were associated with a decrease in FoP
over time, but only among cancer patients. The 2 inter-
ventions did not differ in reducing FoP. Descriptive data
and effect sizes are presented in table 4 .
The analyses showed an effect for time for all secondary
outcome variables (see table 4 for descriptive data). There
was a main effect for illness group regarding depressive
symptoms, physical HRQoL and LS. Specifically, cancer
patients had lower depression scores and showed better
physical HRQoL and higher LS (data not shown). A sig-
nificant interaction between time and illness group
emerged for anxiety [F(3,1017) = 4.47, p ! 0.01], depression
[F(3,1017) = 3.26, p ! 0.05] and the mental component of
HRQoL [F(3,1017) = 4.31, p ! 0.01], indicating an improve-
ment in cancer patients. There was no effect of the inter-
vention type on any of the secondary outcomes.
Ancillary Analysis
In a post hoc analysis, we investigated differences in
therapy characteristics between the groups. More cancer
patients (92.8%) than arthritis patients (62.7%) attended
all 4 group sessions [
(4) = 40.46, p ! 0.001]. Full thera-
py attendance was higher in the CBT group (82.7%) than
in the SET group (69.8%) [
(4) = 11.25, p ! 0.05]. The
combined analysis revealed that only among arthritis
patients full attendance differed between the therapy
groups (CBT: 72.6%; SET: 52.4%) [
(4) = 16.36, p ! 0.01].
In the arthritis sample, no group consisted of less than
8 participants, while most cancer patients took part in
groups of 3–8 attendants [
(7) = 238.42, p ! 0.001]. For
cancer patients, participating in groups with 810 atten-
dants was more frequent in the CBT group than in the
SET group (46.2 vs. 31.3%) [
(7) = 41.76, p ! 0.001]. Di-
agnosis did not affect participation in the booster ses-
sions [
(1) = 0.08, NS]. An ANCOVA with number of
sessions attended and group size as covariates did not
provide evidence for a different pattern of results (data
not shown).
This study has shown that compared to a treatment-
as-usual control group, CBT and SET group interven-
tions were effective in reducing dysfunctional FoP, but
Table 3. ANOVA results for main effects and interaction effects
of intervention, time and diagnosis on FoP total score (intention-
to-treat analysis, missing data imputed, n = 506)
d.f. MS F p
Main effect intervention (int.) 2,500 45.57 2.86 0.058
Main effect time (t) 2,1000 122.46 74.24 <0.001
Main effect diagnosis (diag.) 1,500 626.36 39.26 <0.001
Int. ! t
4,1000 2.24 1.36 0.246
Int. ! diag.
2,500 23.22 1.46 0.234
t ! diag.
2,1000 1.00 0.61 0.546
Int. ! t ! diag.
4,1000 7.97 4.83 0.001
MS = Mean squares.
A completer analysis, based on the data of patients who participated
in all assessments, revealed identical results regarding both primary and
secondary outcomes.
Herschbach /Berg /Waadt /Duran /
/Henrich /Book /Dinkel
Psychother Psychosom 2010;79:31–38
only among cancer patients. The results confirm the ef-
fectiveness of CBT group interventions in cancer
[ 22–24] .
There is mixed support for the effectiveness of support-
ive-expressive or experiential group therapy in chronic
[41–45] , but in our study this approach was ef-
fective in reducing FoP in cancer patients. During in-pa-
tient stay, there was also a reduction in FoP for the control
group of cancer patients, which can be understood as part
of a general improvement. However, only cancer patients
who had the opportunity to work on FoP during the in-
patient stay continued to improve after discharge, while
patients from the control condition deteriorated. This re-
sult underlines that, at least among cancer patients, FoP
is a specific psychological burden in need of treatment.
Contrary to our hypothesis, the interventions did not
reduce dysfunctional FoP in patients with chronic arthri-
tis. Several intervention studies have produced weak re-
[43, 46, 47 ], although there is also some evidence for
Table 4. Means 8 standard deviations and effect sizes (ES) for the primary outcome (FoP-Q) and the second-
ary outcome parameters anxiety (HADS-A), depression (HADS-D), health-related quality of life (SF-12 physi-
cal PCS, SF-12 mental MCS) and general satisfaction with life (FLZ
) (intention-to-treat analysis, missing data
T1 T2 T3 T4 ES
Arthritis CBT
12.482.6 11.782.6 11.682.7 11.482.8
12.582.5 11.882.7 11.882.9 11.882.7
13.282.2 12.582.5
Cancer CBT
11.782.6 11.282.7 10.882.9 10.382.5
11.182.7 10.482.7 10.282.5 9.982.3
11.482.3 10.882.1
Arthritis CBT
9.484.0 8.284.4 9.184.3 8.684.2
9.383.6 8.084.3 8.883.9 8.884.0
Cancer CBT
9.384.0 8.483.9 8.384.0 7.983.8
9.883.9 8.383.9 8.483.9 8.383.6
Arthritis CBT
7.484.3 6.384.1 7.284.3 7.084.5
7.483.7 6.383.8 7.584.1 7.584.0
Cancer CBT
7.083.9 5.683.7 6.084.3 5.784.0
6.783.9 5.983.9 6.284.0 6.083.1
Arthritis CBT
34.788.3 36.789.1 38.189.4 38.689.8
35.887.9 36.488.8 35.588.3 36.387.5
Cancer CBT
39.288.2 40.388.4 42.389.8 42.289.4
38.688.1 39.988.6 42.388.1 41.089.1
Arthritis CBT
39.8810.9 41.4810.3 41.4810.5 41.689.4
38.589.3 41.1810.3 41.1810.2 40.289.3
Cancer CBT
38.388.6 40.989.5 42.2810.3 42.7810.2
37.588.5 40.8810.0 42.0810.3 43.089.2
Arthritis CBT
37.3832.6 41.4835.7 33.7835.0 34.5833.1
39.6834.6 46.8835.5 37.7833.7 37.7831.1
Cancer CBT
44.7831.8 49.0829.6 48.2831.8 46.1825.9
43.7828.6 50.8830.1 42.4827.5 44.4826.4
Sample size primary outcome: arthritis: CBT = 86, SET = 85, control group = 82; cancer: CBT = 84, SET =
79, control group = 90; sample size secondary outcomes: arthritis: CBT = 86, SET = 86; cancer: CBT = 89,
SET = 82; controls did not provide data on primary outcome at T3, thus T3 was not included in the statistical
analysis of the primary outcome. NA = Not applicable; HADS = Hospital Anxiety and Depression Scale.
Psychotherapy of Dysfunctional Fear of
Psychother Psychosom 2010;79:31–38
positive effects, e.g. regarding health care utilization [48] .
Kraaimaat et al.
[46] argue that the ineffectiveness might
be due to the progressive nature of chronic arthritis, al-
lowing only small behavioral changes [see also
49–51 ].
Furthermore, it is possible that disease characteristics
played a significant role in the differential effectiveness
of our approach. Though many illnesses share common
adaptive tasks, it seems that with regard to chronic ar-
thritis and cancer the differences in disease characteris-
tics override the relevance of common psychosocial fea-
Some limitations of our study should be mentioned.
The interpretation of the results is limited by the fact that
we were not able to realize full randomization. However,
all efforts were made to ensure that the control group was
not object to systematic bias. Our protocol did not result
in differences between the control group and the inter-
vention groups in the selected variables. Clearly, there is
no guarantee against unmeasured confounding variables
or underlying bias, e.g. cohort effects. Actually, cohort
effects seem unlikely as the control group was sampled
using the same criteria in the same settings. Further-
more, admission to rehabilitation care is beyond the in-
vestigator’s control. Another point to consider is the pre-
dominance of specific diagnoses, especially in the cancer
group. This might restrict the generalizability of our
This study was supported by the German Federal Ministry of
Education and Research (BMBF) and the German Pension Insur-
ance Administration (VdR), grant No. 01 09889606 (B7 RFB).
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    • "While there are several ongoing trials of FCR interven- tions [28][29][30], to date only one published intervention trial has addressed fear of disease progression, a concept related to FCR, in people with cancer or chronic arthritis [31] . This intervention involved both a cognitive behavioral group and a supportive-expressive group, and it successfully decreased fear of disease progression compared to a control group. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Clinically significant levels of fear of cancer recurrence (FCR) affect up to 49 % of cancer survivors and are more prevalent among women. FCR is associated with psychological distress, lower quality of life, and increased use of medical resources. Despite its prevalence, FCR is poorly addressed in clinical care. To address this problem, we first developed, and pilot tested a 6-week, 2 h, Cognitive-existential group intervention therapy that targeted FCR in survivors of breast or gynecological cancer. Following the positive outcome of the pilot, we are now testing this approach in a randomized clinical trial (RCT). Goal and hypotheses: This multicenter, prospective RCT aims to test the efficacy of the intervention. The study hypotheses are that, compared to a control group, cancer survivors participating in the intervention (1) will have less FCR, (2) will show more favorable outcomes on the following measures: cancer-specific distress, quality of life, illness uncertainty, intolerance of uncertainty, perceived risk of cancer recurrence, and coping skills. We further postulate that the between-group differences will persist three and 6 months post-intervention. Methods Sixteen groups of seven to nine women are being allocated to the intervention or the control group. The control group receives a 6-week, 2 h, structurally equivalent support group. We are recruiting 144 cancer survivors from four hospital sites in three Canadian cities. The sample size was based on the moderate pre/post-test changes found in our pilot study and adjusted to the drop-out rates. Measurements: The primary outcome, FCR, is measured by the Fear of Cancer Recurrence Inventory. Secondary outcomes measured include cancer-specific distress, perceived risk of cancer recurrence, illness uncertainty, intolerance of uncertainty, coping, and quality of life. We use reliable and recognized valid scales. Participants are to complete the questionnaire package at four times: before the first group session (baseline), immediately after the sixth session, and 3 and 6 months post-intervention. Analysis: In the descriptive analysis, comparison of group equivalent baseline variables, identification of confounding/intermediate variables and univariate analysis are planned. Each participant’s trajectory is calculated using Generalized Estimating Equation models to determine the time and group effects, after considering the correlation structures of the groups. An intent-to-treat analysis approach may be adopted. Discussion Our Fear of Recurrence Therapy (FORT) intervention has direct implications for clinical service development to improve the quality of life for patients with breast (BC) and gynecological cancer (GC). Based on our pilot data, we are confident that the FORT intervention can guide the development of effective psychosocial cancer survivorship interventions to reduce FCR and improve psychological functioning among women with BC or GC. Trial registration Dr. Christine Maheu registered the trial with ISRCTN registry (Registration number: ISRCTN83539618, date assigned 03/09/2014).
    Full-text · Article · Dec 2016
    • "Recently, there have been a growing number of studies investigating psychological interventions for FCR. Some of these treatments use verbal and/or written exposure to the worst fear as part of the treatment plan[26,27]. A better understanding of the content of worst fears could help refine current intervention protocols and guide future research in this area. "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose: Few studies have explored coping strategies used by cancer survivors to deal with fear of cancer recurrence (FCR), and little research has been conducted on the specific content of recurrence fears. This study aims to qualitatively explore the strategies used by younger breast cancer survivors to cope with FCR and whether women with low, medium and high levels of FCR employ different coping strategies. An additional aim was to understand the specific content of worst recurrence fears. Method: Twenty Australian and 10 Canadian women aged ≤45 years diagnosed with stages 0-II disease at least 1 year prior completed telephone interviews. The transcripts of audio-taped interviews were analysed using the qualitative methodology of transcendental realism. Results: Women with higher FCR described using distraction and avoidance and fewer coping skills. The fear of death was a common worst fear at all levels of FCR. However, participants with higher FCR described more elaborate fears of death often involving themes of pain and suffering. Cross-cultural differences were not observed. Conclusions: Women with higher FCR report using fewer and more avoidance-based coping techniques. Whilst many participants feared death, those with higher FCR reported more elaborate death fears. Women with high levels of FCR may benefit from learning a greater repertoire of coping skills. Understanding the specific content of FCR can help refine existing psychological treatment protocols for FCR. Implications for FCR treatment are discussed.
    Full-text · Article · Nov 2015
    • "CRC survivors might be more focused on their defecation than on their body. Since CRC survivors with high FCR do not experience their fear as excessive or unreasonable (insight) but the focus seems meanwhile to be on dysfunctional thoughts or behaviors, CRC survivors with high FCR may benefit from cognitive behavior therapy [41][42][43][44]. The study had some limitations. "
    [Show abstract] [Hide abstract] ABSTRACT: Although long-term colorectal cancer (CRC) survivors generally report a good quality of life, fear of cancer recurrence (FCR) remains an important issue. This study investigated whether the Cancer Worry Scale (CWS) can detect high FCR, the prevalence, and characteristics of FCR in CRC survivors. Two hundred and eleven patients who had undergone successful CRC surgery in the period 2003-2010 in the Radboud University Medical Center in the Netherlands were asked to participate. All patients were sent an information letter plus questionnaires for collecting information on demographic and medical variables, FCR, distress, and quality of life. Seventy-six patients (36 %; median age of 67.7 years range 41-88 years) completed the questionnaires a median of 5.1 years after surgery. A cut-off score of 14 or higher on the CWS was optimal to detect high FCR. Twenty-nine patients (38 %) experienced high levels of FCR, characterized by higher levels of distress, post-traumatic stress symptoms, and lower quality of life. These individuals particularly reacted to disease-related triggers, felt helpless, were worried, and experienced limitations in daily functioning. High FCR was not associated with demographic or medical variables. Long after successful CRC surgery, FCR is a serious problem that impairs the quality of life for a substantial proportion of patients. With the CWS, it is possible to detect high FCR and thereby assist survivors in receiving appropriate care.
    Full-text · Article · Jun 2015
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