The effects of safety behaviors on health anxiety: an experimental investigation

Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020

Fear is an adaptive response in the presence of danger. However, when threat is uncertain and continuous, as in the current coronavirus disease (COVID-19) pandemic, fear can become chronic and burdensome. To identify predictors of fear of the coronavirus, we conducted an online survey (N = 439) three days after the World Health Organization declared the coronavirus outbreak a pandemic (i.e., between March 14 and 17, 2020). Fear of the coronavirus was assessed with the newly developed Fear of the Coronavirus Questionnaire (FCQ) consisting of eight questions pertaining to different dimensions of fear (e.g., subjective worry, safety behaviors, preferential attention), and an open-ended question. The predictors included psychological vulnerability factors (i.e., intolerance of uncertainty, worry, and health anxiety), media exposure, and personal relevance (i.e., personal health, risk for loved ones, and risk control). We found four predictors for the FCQ in a simultaneous regression analysis: health anxiety, regular media use, social media use, and risks for loved ones (R² = .37). Furthermore, 16 different topics of concern were identified based participants' open-ended responses, including the health of loved ones, health care systems overload, and economic consequences. We discuss the relevance of our findings for managing people's fear of the coronavirus.

Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020

Fear is an adaptive response in the presence of danger. However, when threat is uncertain and continuous, as in the current coronavirus disease (COVID-19) pandemic, fear can become chronic and burdensome. To identify predictors of fear of the coronavirus, we conducted an online survey (N = 439) three days after the World Health Organization declared the coronavirus outbreak a pandemic (i.e., between March 14 and 17, 2020). Fear of the coronavirus was assessed with the newly developed Fear of the Coronavirus Questionnaire (FCQ) consisting of eight questions pertaining to different dimensions of fear (e.g., subjective worry, safety behaviors, preferential attention), and an open-ended question. The predictors included psychological vulnerability factors (i.e., intolerance of uncertainty, worry, and health anxiety), media exposure, and personal relevance (i.e., personal health, risk for loved ones, and risk control). We found four predictors for the FCQ in a simultaneous regression analysis: health anxiety, regular media use, social media use, and risks for loved ones (R² = .37). Furthermore, 16 different topics of concern were identified based participants' open-ended responses, including the health of loved ones, health care systems overload, and economic consequences. We discuss the relevance of our findings for managing people's fear of the coronavirus.

Three decades of increase in health anxiety: Systematic review and meta-analysis of birth cohort changes in university student samples from 1985 to 2017

Health anxiety can be defined as a multifaceted trait that is primarily characterised by a fear of, or preoccupation with, serious illness. Whereas low levels of health anxiety can be helpful, clinically significant levels are associated with personal suffering and substantial societal costs. As general anxiety is probably on the rise, and the Internet has increased access to health-related information, it is commonly speculated that health anxiety has increased over the past decades. We tested this hypothesis based on a systematic review and meta-analysis of birth cohort mean health anxiety in Western university student samples from 1985 to 2017. Sixty-eight studies with 22 413 student participants were included. The primary analysis indicated that the mean score on the Illness Attitudes Scales had increased by 4.61 points (95 % CI: 1.02, 8.20) from 1985 to 2017. The percentage of general population Internet users in the study year of data collection was not predictive of student mean health anxiety. In conclusion, this study corroborates the hypothesis of an increase in health anxiety, at least in the student population, over the past decades. However, this increase could not be linked to the introduction of the Internet.

A randomised controlled trial of computerised interpretation bias modification for health anxiety

BACKGROUND AND OBJECTIVES

Health anxiety is characterised by a tendency to interpret benign bodily sensations as a sign of serious illness. This study aimed to examine whether computerised cognitive bias modification (CBM-I) training to facilitate benign interpretations of bodily symptoms could reduce these negative interpretations of bodily symptoms, health anxiety and comorbid symptoms.

METHODS

Participants (N = 89) with clinical levels of health anxiety (Short Health Anxiety Inventory [SHAI] scores ≥20) were randomised to receive two internet-delivered 30-min sessions of either CBM-I interpretation training (Intervention) or control CBM-I training over 1-week. Participants were assessed at pre-treatment, post-treatment and 2-weeks follow-up on self-reported health anxiety, cognitions and attributions of bodily symptoms, and comorbid symptoms (e.g., depression).

RESULTS

Results showed significantly reduced catastrophic attributions, health anxiety and related symptoms at post-treatment in both groups, which were maintained at 2-week follow-up. Although there were no significant group differences at post-treatment or follow-up, we found small non-significant effect sizes in favour of the CBM-I Intervention group on health anxiety and cognitions (Cohen's d's between-group effect sizes of 0.28 at post-treatment and d = 0.35 at follow-up on the 18-item Short Health Anxiety Inventory).

LIMITATIONS

The study was conducted online, limiting control over the setting in which participants completed training. Additionally, training was not tailored to the specific symptoms or diseases that participants feared.

CONCLUSIONS

This study is the first to evaluate the effect of internet-delivered CBM-I training targeting benign interpretations of bodily symptoms on health anxiety. Further research is needed before this intervention is disseminated.

The effectiveness of internet-delivered cognitive behavioural therapy for health anxiety in routine care

INTRODUCTION

Randomised controlled trials have shown that internet-delivered cognitive behavioural treatment (iCBT) is an effective treatment for health anxiety, but the effectiveness of these programs in routine care has not been investigated. This study examined the effectiveness of iCBT for health anxiety symptoms in routine care settings in the community.

METHODS

Using an open-trial design, we investigated adherence to, and effectiveness of a 6-lesson iCBT program for health anxiety symptoms amongst individuals (n = 391, mean age 41 years, 64% female) who enrolled in the program either self-guided (n = 312) or under the supervision of community clinicians (general practitioners, psychologists and other allied health professionals) (n = 79). Primary outcome was health anxiety severity on the Short Health Anxiety Inventory (SHAI), and secondary outcomes were depression severity on the Patient Health Questionnaire 9-item (PHQ-9) (depression) and distress (Kessler-10: K-10).

RESULTS

Adherence to the iCBT program was modest (45.6% in the clinician-supervised group, 33.0% in the unguided group), but within-subjects effect sizes were large (SHAI: g = 1.66, 95%CI: 1.45-1.88; PHQ-9: g = 1.12, 95%CI: 0.92-1.32; K-10: g = 1.35, 95%CI: 1.15-1.56).

LIMITATIONS

No control group, lack of follow-up data.

CONCLUSIONS

iCBT is an effective treatment for health anxiety symptoms in routine care, but methods to increase adherence are needed to optimise benefits to participants. Randomised controlled effectiveness trials with long-term follow-up are needed.

Intolerance of Uncertainty Moderates the Relation Between the Choice to Access Health Information and Post-Choice Distress Among Individuals Prone to Health Anxiety

Access to health information has steeply grown, mainly through the availability of online health information. Associated with a number of potential benefits, accessing health information can be non-adaptive and particularly for individuals prone to health anxiety. For those individuals, accessing health information often serves as reassurance seeking to assuage health concerns. However, accessing health information can prompt distress for individuals prone to health anxiety. The present study sought to further understand when accessing health information prompts distress by examining the moderating role of intolerance of uncertainty (IU). Individuals prone to health anxiety (N = 98), as indicated by an elevated score on a self-report measure rather than through formal assessment of meeting criteria for disorders marked by elevated health anxiety (e.g., illness anxiety disorder), participated in a lab-based session where they viewed a provocation of health concerns and were given the choice to either access or avoid further health information. As predicted, participants with high, but not low, IU reported significantly greater distress when they chose to access versus avoid health information. Study results further highlight IU as potentially important for understanding when accessing health information relates to greater negative emotionality. Future directions are discussed.

Psychometric Properties of the Safety Maneuver Scale for Adolescents (SMS-A) and Relationship to Outcomes of a Transdiagnostic Treatment

Safety behaviors are common in anxiety and have been thought to reduce the efficacy of exposure therapy, although some investigations have indicated that safety behaviors may have a non-significant or beneficial impact on exposure efficacy. There have been few investigations of the characteristics and impact of safety behavior use in youth compared to adults, and no known validated, transdiagnostic youth measure of safety behaviors exists. In Study 1, we investigated the psychometric properties of a transdiagnostic measure of adolescent safety behavior use. In Study 2, we examined the relationship between safety behavior use and treatment outcome in 51 anxious and depressed adolescents. Results of Study 1 supported the measure's psychometric properties, while results of Study 2 revealed that decreased safety behavior use is associated with better treatment outcomes. This investigation supports the importance of safety behavior reduction and provides a tool for further investigating adolescent safety behavior use.

Beliefs about safety behaviours in the prediction of safety behaviour use

BACKGROUND

Safety behaviours are ubiquitous across anxiety disorders and are associated with the aetiology, maintenance and exacerbation of anxiety. Cognitive behavioural models posit that beliefs about safety behaviours directly influence their use. Therefore, beliefs about safety behaviours may be an important component in decreasing safety behaviour use. Unfortunately, little empirical research has evaluated this theorized relationship.

AIMS

The present study aimed to examine the predictive relationship between beliefs about safety behaviours and safety behaviour use while controlling for anxiety severity.

METHOD

Adults with clinically elevated levels of social anxiety (n = 145) and anxiety sensitivity (n = 109) completed an online survey that included established measures of safety behaviour use, quality of life, and anxiety severity. Participants also completed the Safety Behaviour Scale (SBS), a measure created for the current study which includes a transdiagnostic checklist of safety behaviours, as well as questions related to safety behaviour use and beliefs about safety behaviours.

RESULTS

Within both the social anxiety and anxiety sensitivity groups, positive beliefs about safety behaviours predicted greater safety behaviour use, even when controlling for anxiety severity. Certain beliefs were particularly relevant in predicting safety behaviour use within each of the clinical analogue groups.

CONCLUSIONS

Findings suggest that efforts to decrease safety behaviour use during anxiety treatment may benefit from identifying and modifying positive beliefs about safety behaviours.

Key mechanisms of cognitive behavioural therapy in irritable bowel syndrome: The importance of gastrointestinal related cognitions, behaviours and general anxiety

BACKGROUND

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterised by abdominal pain and altered bowel movements. Cognitive behavioural therapy (CBT) has been shown to be effective in reducing symptom severity in IBS and enhancing quality of life/functioning. The present study sought to identify how CBT achieves change in these outcomes.

METHOD

Secondary analysis was conducted on 149 patients with irritable bowel syndrome who had been randomised to cognitive behavioural therapy plus an antispasmodic medication or antispasmodic alone. Single and sequential mediation was modelled using structural equation modelling. Gastrointestinal (GI) related avoidance behaviour, safety behaviour, cognitions and general anxiety were included as mediators.

RESULTS

GI safety behaviours, cognitions and general anxiety mediated treatment effect on the outcomes of symptom severity and work and social adjustment. Avoidance behaviour was not a significant mediator for either outcome. Sequential mediation models indicated that unhelpful GI related cognitions reduced before anxiety did, and this sequential path (R➔GI related cognitions➔anxiety➔outcome) was significant for both symptom severity (b = -0.22, CI [-0.40 to -0.90], p = .005) and work and social adjustment (b = -0.26, CI [-0.44 to -0.11], p = .003) where 'R' is randomisation. Reduction in GI safety behaviours also preceded reduction in anxiety. This sequence (R ➔GI safety behaviours➔anxiety➔outcome) was significant for both symptom severity (b = -0.11, CI [-0.24 to -0.01], p = .049) and work and social adjustment (b = -0.12, CI [-0.23 to -0.03], p = .03).

CONCLUSION

Results suggest that it is important for psychological treatments to target IBS specific factors for change.

Affect and worry during a checking episode: A comparison of individuals with symptoms of obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, body dysmorphic disorder, illness anxiety disorder, and panic disorder

Checking behavior (CB) occurs in a variety of disorders such as obsessive-compulsive (OCD), body dysmorphic (BDD), illness anxiety (IA), and panic disorder (PD), as well as anorexia (AN) and bulimia nervosa (BN). Etiological models of these disorders - with the exception of those for PD - postulate that CB mainly occurs in situations characterized by negative affect and serves to regulate it. We aimed to test these assumptions: N = 386 individuals with a self-reported diagnosis of one of the disorders rated their affect at baseline, directly before a remembered CB episode, during, immediately afterwards, and 15 and 60 minutes afterwards, and rated their endorsement of different functions of CB. The results show that transdiagnostically negative affect is significantly higher before CB compared to baseline, and is significantly reduced from before CB to all post-CB assessments. Reduction of negative affect and Attainment of certainty were the sole functions predicting the affective course during CB, and most prominently reported transdiagnostically. Assumptions of the etiological models were confirmed, suggesting that exposure and ritual prevention should be examined across disorders. As attainment of certainty seems to be predictive for the course of CB, this might be targeted in cognitive interventions.

An examination of mindfulness skills in terms of affect tolerance among individuals with elevated levels of health anxiety

BACKGROUND AND OBJECTIVES

Affect tolerance factors, including anxiety sensitivity, intolerance of uncertainty, and emotional distress tolerance, have been implicated in the exacerbation of health anxiety. Therefore, identifying methods to improve affect tolerance in health anxious populations is imperative. Despite the link between mindfulness and greater affect tolerance in non-clinical populations, no work has examined the role of mindfulness skills in terms of affect tolerance among individuals with elevated health anxiety. The aim of the current study was to examine the unique contribution of mindfulness skills in terms of distress tolerance, anxiety sensitivity, and intolerance of uncertainty.

METHODS

Participants were 218 undergraduates with clinically elevated levels of health anxiety (75.7% female; Mage = 19.53, SD = 3.16, Range = 18-45) who completed self-report measures for course credit.

RESULTS

Findings indicated that, after controlling for theoretically relevant covariates, greater acting with awareness, non-judgment, and non-reactivity were uniquely associated with greater distress tolerance, and greater non-reactivity was associated with lower levels of intolerance of uncertainty. Though none of the mindfulness skills emerged as specific individual predictors of anxiety sensitivity, these skills collectively accounted for unique variance in anxiety sensitivity.

CONCLUSIONS

These findings suggest that mindfulness skills may be helpful in targeting affect tolerance factors among individuals with elevated health anxiety.

The combination of health anxiety and somatic symptoms: a prospective predictor of healthcare usage in primary care

Extant research provides equivocal conclusions if the combined presentation of health anxiety with severe somatic symptoms confers risk for greater future primary care usage. The present study further examined the combination of health anxiety and somatic symptoms as a predictor of healthcare usage in primary care. Using a prospective longitudinal design, a large sample (N = 530) of patients presenting for treatment at a community health center completed self-report measures assessing health anxiety and somatic symptom severity. A medical record review at the time of questionnaire administration and 1 year following that administration was completed to assess the frequency of medical visits during the preceding and subsequent year. As expected, the interactive effect between health anxiety and somatic symptom severity predicted greater subsequent year medical visits. Covariates included preceding year medical visits, sociodemographic variables, body mass index, smoking status, and depressive symptom severity. Simple effects indicated that health anxiety predicted greater subsequent year medical visits when coupled with relatively severe, but not mild, somatic symptoms. Assessing health anxiety and somatic symptom severity in primary care settings could be important for identifying individuals at risk for future frequent healthcare visits and who may benefit from intervention.

The effects of the non-contingent presentation of safety signals on the elimination of safety behaviors: An experimental comparison between individuals with low and high obsessive-compulsive profiles

BACKGROUND AND OBJECTIVES

Safety behaviors, defined as engagement in avoidance within safe environments, are a key symptom of obsessive-compulsive and related disorders. They may interfere with daily functioning and as such their emission should be reduced. The purpose of the current study is to investigate the effects of the non-contingent presentation of safety signals (cues produced by safety behaviors) on reducing safety behaviors in participants self-reporting low and high OCD profiles.

METHODS

In total, 32 participants were asked to play a game to gain points and avoid their loss. After having developed avoidance behavior, evidenced by maintaining all of their earned points, they were exposed to safe environments where no point loss was programmed. In Test 1, safety cues (blue bar) were produced contingent on performing safety behaviors. In Test 2, safety cues were presented continuously without any response requirement.

RESULTS

Findings demonstrated that high OCD group displayed higher rates of safety behaviors than low OCD group. However, exposure to the non-contingent presentation of safety signals eliminated their emission in both groups.

LIMITATIONS

Future studies need to evaluate the effects of different non-contingent schedules on the suppression of safety behaviors.

CONCLUSIONS

These findings contribute to the literature by demonstrating that non-contingent introduction of safety signals eliminated safety behaviors completely, even in high OCD participants, who performed safety behavior at higher rates. Such a treatment protocol may ameliorate exposure therapy in which response prevention constitutes a key element and is generally associated with increased drop-out rates.

Safety Behavior After Extinction Triggers a Return of Threat Expectancy

Safety behavior is involved in the maintenance of anxiety disorders, presumably because it prevents the violation of negative expectancies. Recent research showed that safety behavior is resistant to fear extinction. This fear conditioning study investigated whether safety behavior after fear extinction triggers a return of fear in healthy participants. Participants learned that two stimuli (A and C) were followed by an aversive loud noise ("threat"), and one stimulus (B) was not. Participants then learned to use safety behavior that prevented the loud noise. Next, A and C were no longer followed by the loud noise, which typically led to extinction of threat expectancy. Safety behavior then became available again for C, but not for A and B. All participants used safety behavior on these C trials. In a final test phase, A, B, and C were presented once without the availability to use safety behavior. At each stimulus presentation, participants rated threat expectancy by indicating to what extent they expected that the loud noise would follow. Compared with the last extinction trial, threat expectancy increased for C in the test phase, whereas it did not increase for A and B. Hence, safety behavior after the extinction of classically conditioned fear caused a partial return of fear. The findings suggest that safety behavior may be involved in relapse after exposure-based therapy for anxiety disorders.

Preventative and restorative safety behaviors: Effects on exposure treatment outcomes and risk for future anxious symptoms

OBJECTIVES

Two studies investigated the differential effect of preventative and restorative safety behaviors on the treatment and development of anxiety and depression.

METHOD

Study 1 investigated the impact of preventative and restorative safety behaviors in prolonged exposure therapy among US veterans with PTSD (N = 95). Study 2 was a 3-month prospective study investigating preventative and restorative safety behaviors as risk factors for anxious and depressive symptoms in a non-clinical sample (N = 84).

RESULTS

The results of Study 1 showed that both preventative and restorative safety behaviors were associated with worse treatment outcomes (both PTSD symptoms and depressive symptoms). The results of Study 2 found that preventative, but not restorative, safety behaviors predicted increases in future anxious symptoms. Neither preventative nor restorative safety behaviors conferred risk for increases in future depression symptoms (anhedonia).

CONCLUSIONS

Preventative and restorative safety behaviors impact PTSD treatment outcomes, while only preventative safety behaviors predict future anxiety.

The impact of exposure-based cognitive behavior therapy for severe health anxiety on self-rated health: Results from a randomized trial

OBJECTIVE

Self-rated health (SRH) has been shown to be a stable predictor of illness and mortality. Improvement in SRH, even in the absence of change in objective health, predicts better health and reduced mortality. Severe health anxiety (SHA) is characterized by fear of illness and distorted health perception. The objective of the present study was to investigate if exposure-based cognitive behavior therapy (CBT) for SHA can lead to improvement in SRH and whether this improvement is mediated by reduced health anxiety.

METHODS

Data were collected from a randomized controlled trial where participants with SHA were allocated to 12weeks of exposure-based CBT (n=99) for SHA or to a no treatment control condition (n=33). The mediation analysis was based on SRH- and health anxiety data collected weekly during the treatment phase.

RESULTS

Linear mixed effects models analysis showed a significant interaction effect of group and time indicating superior improvements in SRH in exposure-based CBT compared to the control condition (Z=2.69, p=0.007). The controlled effect size was moderately large (d=0.64) and improvements were stable at 1-year follow-up. Reduced health anxiety was a significant mediator of improvement in SRH.

CONCLUSIONS

12weeks of exposure-based CBT for SHA can lead to significant improvements in SRH. Considering the previously established importance of SRH as a predictor for disease and mortality, exposure-based CBT for severe health anxiety may lead to improvements on several important health parameters, possibly even increasing the likelihood of longevity.

Psychological Predictors of Health Anxiety in Response to the Zika Virus

The threat of a United States (U.S.) Zika virus pandemic during 2015-2016 was associated with public anxiety. Such threats represent opportunities to examine hypotheses about health anxiety. The present study investigated psychological predictors of Zika-related anxiety during the 2015-2016 outbreak. U.S. adults (N = 216) completed a battery of measures assessing Zika-related anxiety as well as psychological variables hypothesized to predict anxious responding to the threat of a domestic Zika outbreak. Contrary to hypotheses, regression analyses indicated that only contamination severity overestimates and greater Zika knowledge significantly predicted Zika-related anxiety. Study limitations and clinical implications are discussed.

The mediating effect of mindful non-reactivity in exposure-based cognitive behavior therapy for severe health anxiety

Exposure-based cognitive behavior therapy (CBT) has been shown to be effective in the treatment of severe health anxiety, but little is known about mediators of treatment effect. The aim of the present study was to investigate mindful non-reactivity as a putative mediator of health anxiety outcome using data from a large scale randomized controlled trial. We assessed mindful non-reactivity using the Five Facets Mindfulness Questionnaire-Non-Reactivity scale (FFMQ-NR) and health anxiety with the Short Health Anxiety Inventory (SHAI). Participants with severe health anxiety (N=158) were randomized to internet-delivered exposure-based CBT or behavioral stress management (BSM) and throughout the treatment, both the mediator and outcome were measured weekly. As previously reported, exposure-based CBT was more effective than BSM in reducing health anxiety. In the present study, latent process growth modeling showed that treatment condition had a significant effect on the FFMQ-NR growth trajectory (α-path), estimate=0.18, 95% CI [0.04, 0.32], p=.015, indicating a larger increase in mindful non-reactivity among participants receiving exposure-based CBT compared to the BSM group. The FFMQ-NR growth trajectory was significantly correlated with the SHAI trajectory (β-path estimate=-1.82, 95% CI [-2.15, -1.48], p<.001. Test of the indirect effect, i.e. the estimated mediation effect (αβ) revealed a significant cross product of -0.32, which was statistically significant different from zero based on the asymmetric confidence interval method, 95% CI [-0.59, -0.06]. We conclude that increasing mindful non-reactivity may be of importance for achieving successful treatment outcomes in exposure-based CBT for severe health anxiety.

The Role of Emotion Reactivity in Health Anxiety

Emotion reactivity, defined as heightened sensitivity, intensity, and persistence of emotional states, has been shown to contribute to the exacerbation of anxiety. However, the association between emotion reactivity and health anxiety has yet to be examined. The aim of the present investigation was to examine the unique predictive ability of emotion reactivity in terms of health anxiety in a sample of medically healthy undergraduates ( n = 194; 59.3% female, M_age = 19.42, SD = 1.51, range = 18-26 years; 84.0% Caucasian). Findings indicated that, after controlling for the effects of gender, age, and anxiety sensitivity, greater emotion reactivity significantly predicted greater overall health anxiety (3.1% variance), as well as higher levels of affective (4.1% unique variance) and behavioral (4.8% unique variance) components. Findings suggest that experiencing emotions more frequently, intensely, and for longer durations of time prior to returning to baseline are associated with greater health preoccupations.

An exploration of the relationship between use of safety-seeking behaviours and psychosis: A systematic review and meta-analysis

Safety-seeking behaviours are responses employed to protect against perceived threat. In relation to anxiety disorders, safety-seeking behaviours have been implicated in both the formation and maintenance of distress. Several studies have highlighted similar findings in relation to psychosis; however, this literature has not yet been synthesized. This review is, therefore, being conducted in order to synthesize the literature on safety seeking in people with psychosis to increase the understanding of this relationship. A systematic search identified and included 43 studies comprising 2,592 participants, published between 1995 and 2015. The results indicated that people experiencing psychosis commonly respond to their experiences with behavioural and cognitive strategies intended to manage their difficulties. In relation to safety seeking, avoidance, and resistance, there was a pattern that these responses are associated with increased distress and appraisals of threat. The results relating to engagement response styles showed the opposite pattern. These results provide support for cognitive models of safety seeking and psychosis with many of the meta-analyses reported here showing a clear pattern of association between behavioural responses and distress. However, the results reported within individual studies are mixed. This appears to be particularly true with the response style of distraction, with our analyses unable to clarify this relationship. It is possible that the mixed results could reflect the complexities in defining safety seeking and distinguishing it from coping in this population. The clinical implications of this are discussed.

Disconfirming contamination-related threat beliefs by exposure plus safety behavior

BACKGROUND AND OBJECTIVES

Safety behavior (SB) is detrimental to the beneficial effects of exposure, because it prevents patients from obtaining evidence that disconfirms their excessive threat beliefs. However, previous studies showed that cleaning SB during exposure to a contaminant does not prevent a reduction in feelings of contamination, fear of contamination, danger, and disgust (CFDD). We aimed to directly examine the effect of SB during exposure to a contaminant on threat beliefs associated with CFDD.

METHOD

Healthy participants were randomly assigned to one of three groups: repeated exposure to a contaminant whilst abstaining from SB (exposure plus response prevention; E + RP); with the use of disinfectant wipes after each instance of exposure (exposure plus SB; E + SB); or no exposure or safety behavior (control condition). Participants identified their threat belief associated with the contaminant and rated CFDD and the degree to which they believed their threat belief at the pre- and post-test.

RESULTS

The E + RP and E + SB condition resulted in a larger decrease of CFDD and threat belief ratings than the control condition, whereas these reductions did not differ between the E + RP and E + SB condition.

LIMITATIONS

Results were obtained from a nonclinical sample, and with a single session of exposure.

CONCLUSION

Cleaning SB did not impede the beneficial effects of exposure.

Internet-Based Extinction Therapy for Worry: A Randomized Controlled Trial

Worry is a common phenotype in both psychiatric patients and the normal population. Worry can be seen as a covert behavior with primary function to avoid aversive emotional experiences. Our research group has developed a treatment protocol based on an operant model of worry, where we use exposure-based strategies to extinguish the catastrophic worry thoughts. The aim of this study was to test this treatment delivered via the Internet in a large-scale randomized controlled trial. We randomized 140 high-worriers (defined as > 56 on the Penn State Worry Questionnaire [PSWQ]) to either Internet-based extinction therapy (IbET) or to a waiting-list condition (WL). Results showed that IbET was superior to WL with an overall large between-group effect size of d = 1.39 (95% confidence interval [1.04,1.73]) on the PSWQ. In the IbET group, 58% were classified as responders. The corresponding figure for WL participants was 7%. IbET was also superior to the WL on secondary outcome measures of anxiety, depression, meta-cognitions, cognitive avoidance, and quality of life. Overall treatment results were maintained for the IbET group at 4- and 12-month follow-up. The results from this trial are encouraging as they indicate that worry can be targeted with an accessible and novel intervention for worry. Replication trials with active control group are needed.

Obsessions and compulsions in the lab: A meta-analysis of procedures to induce symptoms of obsessive-compulsive disorder

Efficacious induction procedures of symptoms of obsessive-compulsive disorder (OCD) are necessary in order to test central tenets of theories on OCD. However, the efficacy of the current range of induction procedures remains unclear. Therefore, this meta-analysis set out to examine the efficacy of induction procedures in participants with and without OCD symptoms. Moreover, we explored whether the efficacy varied across different moderators (i.e., induction categories, symptom dimensions of OCD, modalities of presentation, and level of individual tailoring). In total we included 4900 participants across 90 studies. The analyses showed that there was no difference in studies using subclinical and clinical participants, confirming the utility of analogue samples. Induction procedures evoked more symptoms in (sub)clinical OCD than in healthy participants, which was most evident in the contamination symptom dimension of OCD. Analysis within (sub)clinical OCD showed a large effect size of induction procedures, especially for the threat and responsibility category and when stimuli were tailored to individuals. Analysis within healthy participants showed a medium effect size of induction procedures. The magnitude of the effect in healthy individuals was stronger for mental contamination, thought-action fusion and threat inductions.

Pilot trial of a therapist-supported internet-delivered cognitive behavioural therapy program for health anxiety

Cognitive behavioural therapy (CBT) is an effective treatment for health anxiety, but more research is needed to evaluate accessible, low cost ways of delivering CBT. Internet CBT may be effective, but there are no iCBT programs available outside of Sweden. We developed the first English-language clinician-guided iCBT program for health anxiety and conducted an open pilot trial (n = 16) to examine its acceptability, and impact on health anxiety and comorbidity, disability, and the cognitive and behavioural factors thought to maintain the disorder (e.g., catastrophising, hypervigilance). 13/16 participants completed the program (81% adherence). We found large and significant reductions in health anxiety, depression, distress, anxiety and disability (g's > 1.0), dysfunctional cognitions, behaviours and body vigilance between pre- and post-treatment, which were maintained at 3-month follow-up. The results provide preliminary support for the use of iCBT for health anxiety. Randomised controlled efficacy trials are now needed to evaluate this program.

Fears, Coping Styles, and Health Behaviors: A Comparison of Patients With Hypochondriasis, Panic Disorder, and Depression

Research into correlates of illness anxiety disorder (formerly hypochondriasis) rarely applies comprehensive assessments of health behavior. Moreover, studies on phenomenological varieties of clinical health anxiety are scarce. We examined health behavior, fear, and acceptance of death and dying, and coping with a hypothetical bodily disease in patients with hypochondriasis, panic disorder, depression, and healthy controls (all groups n = 30) using self-rated questionnaires. ANOVA with Dunnett-T3 post hoc tests revealed no group differences in health behavior. The hypochondriasis and panic disorder groups showed more fear and less acceptance of death and dying than patients with depression and controls. Groups did not differ concerning coping strategies. Patients with hypochondriasis ruminated more when confronted with their most feared rather than another disease. Patients apparently overestimate the danger of a specific disease, but without underestimating their coping abilities. A therapeutic focus on fear of death and dying via cognitive interventions and exposure is recommended.

The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective

In the context of clinical anxiety, safety behaviors are actions performed to prevent, escape, or minimize feared catastrophes and/or associated distress. Research consistently implicates safety behaviors in the development and maintenance of anxiety disorders; accordingly, safety behaviors are traditionally eliminated during exposure treatments for pathological anxiety. The notion that safety behaviors are ubiquitously deleterious in the context of exposure has recently been challenged, yet findings regarding safety behaviors' effects on exposure outcomes are limited, mixed, and controversial. Furthermore, developments in explanatory models for exposure's effectiveness (e.g., inhibitory learning theory) highlight other possible consequences of safety behaviors performed during exposure. Unfortunately, these theoretical advances are neglected in experimental research. The present review critically examines the literature addressing the role of safety behaviors in exposure therapy from an inhibitory learning perspective. Limitations, future directions, and clinical recommendations are also discussed.

Prevalence of non-adherence among psychiatric patients in Jordan, a cross sectional study

Background

It has been estimated that up to 50% of any patient population is at least partially non-adherent to their prescribed treatment. Identifying barriers to adherence is required to develop effective interventions for psychiatric patients.

Objective

To explore the prevalence and factors of non-adherence among psychiatric patients present at four psychiatric clinics.

Method

A cross-sectional questionnaire-based study. A sample of psychiatric patients attending outpatient psychiatric clinics was enrolled between March and April 2011.

Results

A total of 243 psychiatric patients took part in this study with the majority of patients (92.5%) being prescribed more than one psychiatric disorder. The majority (64.2%) of the patients was classified as non-adherent according to the Morisky adherence questionnaire and forgetfulness was the most prevalent reason for that.

Conclusions

Non-adherence is a common and important issue among psychiatric patients. Polypharmacy, safety concerns and lack of insight towards the prescribed treatment were reported as the main reasons of non-adherence.

The functional value of preventive and restorative safety behaviors: A systematic review of the literature

Safety behaviors are unnecessary actions used to prevent, escape from, or reduce the severity of a perceived threat. Most cognitive-behavioral theorists posit that the use of safety behaviors during exposure is maladaptive because they interfere with fear reduction. However, there is growing evidence suggesting that the use of safety behaviors can facilitate exposure. In general, the findings are mixed as to whether safety behaviors should be made available during exposure-based interventions. The aim of the current review was to evaluate whether safety behaviors should be made accessible during exposure, and whether under certain circumstances, they facilitate or hinder important exposure outcomes. We examined two functional types of safety behaviors: preventive and restorative. A thorough review of the safety behavior literature from the last three decades was conducted. The evidence suggests (restorative) safety behaviors that allow for full confrontation with a core threat do not interfere with meaningful indicators of successful exposure, whereas (preventive) safety behaviors that hinder engagement with the stimulus or experience may weaken exposure outcomes. The theoretical and clinical implications of these findings are discussed and future directions in the investigation of safety behaviors are suggested.

The Effects of Safety Behavior Directed Towards a Safety Cue on Perceptions of Threat

Safety behavior involves precautions to prevent or minimize a feared outcome, and is involved in the maintenance of anxiety disorders. Earlier research has shown that safety behavior prevents the extinction of conditioned fear and maintains threat expectations. This study tested whether safety behavior directed towards an objectively safe stimulus increases the perceived threat of that stimulus when it is subsequently experienced in the absence of the safety measure. In a conditioning task, participants first learned that one "danger" cue (A) was followed by shock and two "safety" cues (B, C) were not. Then they learned to apply safety behavior during A trials, which prevented the shock. Next, the experimental group, and not the control group, was given the opportunity to display safety behavior to C trials, which had never been coupled with the shock. In a subsequent test phase, A, B, and C were presented without the opportunity for participants to engage in safety behavior. Results showed that safety behavior increased shock expectancy to C in the test phase and maintained a preexisting shock expectancy in the experimental group, but not in the control group. This is the first study to show that safety behavior can maintain threat appraisal to stimuli that only ever acquired threat indirectly. This may be a possible mechanism for the origin of biased threat beliefs, superstitious behaviors, and irrational fears. It is also practically relevant: safety behavior reduces actual danger, but in relatively safe situations, its potential costs may outweigh the benefits.

A Preliminary Investigation into Worry about Mental Health: Development of the Mental Health Anxiety Inventory

BACKGROUND

Worry about physical health is broadly referred to as health anxiety and can range from mild concern to severe or persistent anxiety such as that found in DSM-IV hypochondriasis. While much is known about anxiety regarding physical health, little is known about anxiety regarding mental health. However, recent conceptualizations of health anxiety propose that individuals can experience severe and problematic worry about mental health in similar ways to how people experience extreme worry about physical health.

AIMS

Given the paucity of research in this area, the aim of the current study was to explore anxiety regarding mental health through validation of the Mental Health Anxiety Inventory (MHAI), a modified version of the Short Health Anxiety Inventory.

METHOD

The MHAI, and measures of state anxiety (Depression, Anxiety and Stress Scales-21), trait worry (Penn State Worry Questionnaire), and health anxiety (Short Health Anxiety Inventory) were administered to 104 adult volunteers from the general community.

RESULTS

The MHAI demonstrated high internal consistency, acceptable test-retest reliability, and good construct validity when correlated with other measures of anxiety. Results also indicated that participants worried about their mental health and physical health equally, and that almost 9% of participants reported levels of mental health anxiety that were potentially problematic.

CONCLUSION

Preliminary results suggest that a small proportion of adults in the community may experience high levels of mental health anxiety requiring treatment, and that the MHAI, if validated further, could be a useful tool for assessing this form of anxiety.

Safety Behavior Increases Obsession-Related Cognitions About the Severity of Threat

This study investigated whether checking behavior, the most common safety behavior in obsessive-compulsive disorder (OCD), contributes to the development of OCD symptoms. Ninety healthy undergraduates spent a week between a pre- and posttest either actively engaging in clinically representative checking behavior on a daily basis (experimental group, n=30), monitoring their normal checking behavior (monitor group, n=30), or received no instructions on checking behavior (control group, n=30). Cognitions about the severity of threat increased from pre- to posttest in the experimental group, but not in the monitor and control groups. Cognitions about the importance of checking decreased in the monitor group. The results indicate that checking behavior contributes directly to the exacerbation of OCD symptoms. Together with the findings of previous studies, this suggests that safety behavior may be involved in the development of anxiety disorders and OCD. Potential mechanisms of how engaging in safety behavior increases threat perception are discussed.

Therapeutic Process During Exposure: Habituation Model

The current paper outlines the habituation model of exposure process, which is a behavioral model emphasizing use of individually tailored functional analysis during exposures. This is a model of therapeutic process rather than one meant to explain the mechanism of change underlying exposure-based treatments. Habitation, or a natural decrease in anxiety level in the absence of anxiety-reducing behavior, might be best understood as an intermediate treatment outcome that informs therapeutic process, rather than as a mechanism of change. The habituation model purports that three conditions are necessary for optimal benefit from exposures: 1) fear activation, 2) minimization of anxiety-reducing behaviors, and 3) habituation. We describe prescribed therapist and client behaviors as those that increase or maintain anxiety level during an exposure (and therefore, facilitate habituation), and proscribed therapist and client behaviors as those that decrease anxiety during an exposure (and therefore, impede habituation). We illustrate model-consistent behaviors in the case of Monica, as well as outline the existing research support and call for additional research to further test the tenets of the habituation model as described in this paper.

Health Behavior in Hypochondriasis

The relationship between health behavior and hypochondriasis has not yet been sufficiently examined, as previous studies investigated only individual dimensions of health behavior. In the present study, we extend current literature by examining multiple dimensions of health behavior. One hundred twenty-six participants, consisting of 40 participants with a primary diagnosis of hypochondriasis, 41 participants with a primary diagnosis of anxiety disorder, and 45 healthy controls, completed a multidimensional questionnaire for the assessment of health behavior and other measures for the evaluation of general psychopathology, illness anxiety, depression, and general anxiety. Patients with hypochondriasis revealed a less active way of life (d = 0.89) and lower hygiene (d = 0.60) than healthy controls, but did not differ from healthy controls regarding their compliance to medical recommendations. No differences were found in substance avoidance, security orientation, and diet. Hypochondriasis-specific behavior should be monitored in the treatment of the disorder.

Tracing "Fearbola": Psychological Predictors of Anxious Responding to the Threat of Ebola

Serious illnesses such as Ebola are often highly publicized in the mass media and can be associated with varying levels of anxiety and compensatory safety behavior (e.g., avoidance of air travel). The present study investigated psychological processes associated with Ebola-related anxiety and safety behaviors during the outbreak in late 2014. Between October 30 and December 3, 2014, which encompassed the peak of concerns and of the media's attention to this particular outbreak, 107 university students completed a battery of measures assessing fear of Ebola, performance of safety behaviors, factual knowledge of the virus, and psychological variables hypothesized to predict Ebola-related fear. We found that while our sample was generally not very fearful of contracting Ebola, the fear of this disease was correlated with general distress, contamination cognitions, disgust sensitivity, body vigilance, and anxiety sensitivity-related physical concerns. Regression analyses further indicated that anxiety sensitivity related to physical concerns and the tendency to overestimate the severity of contamination were unique predictors of both Ebola fear and associated safety behaviors. Implications for how concerns over serious illness outbreaks can be conceptualized and clinically managed are discussed.

Anxiety sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria

BACKGROUND

Online medical information seeking has become an increasingly common behavior. Despite the benefits of easily accessible medical information on the Internet, researchers have identified a vicious cycle of increased physical health concerns and online medical information seeking known as "cyberchondria". Despite proposed theoretical models of cyberchondria, there is a dearth of research investigating risk factors for the development of cyberchondria. Two potential risk factors are anxiety sensitivity (AS) and intolerance of uncertainty (IU).

METHODS

The current study investigated the relationships among AS, IU, and cyberchondria in a large community sample. Participants (N=526) completed self-report questionnaires via online crowdsourcing.

RESULTS

Structural equation models utilizing latent variables revealed a significant unique positive relationship between AS, as well as the IU Inhibitory lower-order factor, and cyberchondria, controlling for the effects of health anxiety. Additionally, results revealed a significant unique relationship between the IU Inhibitory factor and mistrust of medical professionals, a proposed cyberchondria-relevant construct.

LIMITATIONS

The cross-sectional data in the current study do not offer a true test of AS and IU as risk factors. However, establishing these unique relationships is an important step forward in the literature.

CONCLUSIONS

The results of the current study suggest the potential importance of both AS and IU in the development of cyberchondria. Future research is needed to establish the temporal precedence of elevated AS and/or IU to determine if they are true risk factors or simply correlates of cyberchondria.

The effects of preventive and restorative safety behaviors on a single-session of exposure therapy for contamination fear

BACKGROUND AND OBJECTIVES

Recent research suggests that safety behaviors (SB) may not preclude treatment gains in exposure-based therapy for obsessive-compulsive disorder. However, it is relatively unknown what specific types of SBs may be detrimental to the therapeutic process, with some arguing that SBs be classified based on their function. The current study sought to examine the extent to which different SBs enhanced or weakened symptoms of contamination fear during a single session of exposure.

METHODS

Sixty-seven non-clinical students were randomly assigned to one of three conditions: (1) exposure with no SBs (NSB), (2) exposure with preventive SBs (PSB), or (3) exposure with restorative SBs (RSB).

RESULTS

Among the primary outcome measures, greater reductions in fear and behavioral avoidance were found for RSB in comparison to PSB, and the gains made by RSB were generalizable to other sources of potential contamination. Furthermore, RSB resulted in more rapid reductions in fear and disgust across repeated exposure trials.

LIMITATIONS

Limitations include the use of a nonclinical student sample.

CONCLUSIONS

Overall, the current study suggests that RSB may be beneficial as an adjunct to therapy whereas PSB are potentially detrimental. Results of the study are discussed in terms of exposure theories and the treatment of anxiety disorders.

Behavior as information about threat in anxiety disorders: a comparison of patients with anxiety disorders and non-anxious controls

BACKGROUND

Gangemi, Mancini, and van den Hout (2012) argued that anxious patients use safety behaviors as information that the situation in which the safety behaviors are displayed is dangerous, even when that situation is objectively safe. This was concluded from a vignette study in which anxious patients and non-clinical controls rated the dangerousness of scripts that were safe or dangerous and in which the protagonist did or did not display safety behaviors. Patients were more likely to take safety behavior as evidence that the situation was dangerous, especially in safe situations. Their non-clinical group may not have been psychologically naïve. We critically replicated the Gangemi et al. study using a psychologically non-informed control group.

METHOD

The same materials were used and patients (Obsessive Compulsive Disorder, Panic Disorder, Social Phobia; n = 30 per sub-group) were compared to matched non-patients. Using Bayesian statistics, data from the Gangemi et al. samples and the present groups were (re-)analyzed testing the hypothesis relative to non-patients, patients infer threat from safety behaviors, especially if displayed in safe situations.

RESULTS

The Gangemi et al. data yielded a Bayes factor of 3.31 in support of the hypothesis. The present Bayes Factor was smaller (2.34), but strengthened the support for the hypothesis expressed by an updated Bayes factor of 3.31 × 2.34 = 7.75.

CONCLUSIONS

The finding that anxious patients infer threat from safety behaviors, in particular in safe contexts, was corroborated, suggesting one way in which safety behaviors are involved in the maintenance of anxiety disorders.