The Short Health Anxiety Inventory: Psychometric Properties and Construct Validity in a Non-clinical Sample

How do elements of a reduced capacity to withstand uncertainty relate to the severity of health anxiety?

Intolerance of uncertainty (IU)--a multidimensional cognitive vulnerability factor--is associated with a variety of anxiety disorders and health anxiety (HA). To date, few studies have assessed whether IU dimensions (prospective and inhibitory IU) are differentially associated with HA and whether their contributions are independent of anxiety sensitivity (AS). This study addressed these issues using independent community (n = 155; 81% women) and undergraduate (n = 560; 86% women) samples. Results indicated that prospective IU, but not inhibitory IU, had significant positive associations with HA in community dwellers and undergraduate students. AS somatic and cognitive concerns were also significant predictors among both samples. In addition, severity of IU dimensions among individuals reporting elevated HA were compared against individuals diagnosed with generalized anxiety disorder, social anxiety disorder, panic disorder, and obsessive-compulsive disorder. Results indicated minimal differences between those with elevated HA and each of the anxiety disorder diagnoses. Findings lend support to the unique transdiagnostic nature of IU and support commonalities between HA and anxiety disorders.

Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators

The present investigation employed meta-analysis to examine the efficacy of cognitive-behavioral therapy (CBT) for hypochondriasis/health anxiety as well as potential moderators that may be associated with outcome. A literature search revealed 15 comparisons among 13 randomized-controlled trials (RCTs) with a total sample size of 1081 participants that met inclusion criteria. Results indicated that CBT outperformed control conditions on primary outcome measures at post-treatment (Hedges's g = 0.95) and at follow-up (Hedges's g = 0.34). CBT also outperformed control conditions on measures of depression at post-treatment (Hedges's g = 0.64) and at follow-up (Hedges's g = 0.35). Moderator analyses revealed that higher pre-treatment severity of hypochondriasis/health anxiety was associated with greater effect sizes at follow-up visits and depression symptom severity was significantly associated with a lower in effect sizes at post-treatment. Although effect size did not vary as a function of blind assessment, smaller effect sizes were observed for CBT vs. treatment as usual control conditions than for CBT vs. waitlist control. A dose response relationship was also observed, such that a greater number of CBT sessions was associated with larger effect sizes at post-treatment. This review indicates that CBT is efficacious in the treatment of hypochondriasis/health anxiety and identifies potential moderators that are associated with outcome. The implications of these findings for further delineating prognostic and prescriptive indicators of CBT for hypochondriasis/health anxiety are discussed.

Computerized attention retraining for individuals with elevated health anxiety

BACKGROUND AND OBJECTIVES

Current cognitive-behavioral theorists conceptualize hypochondriasis as excessive health anxiety (HA). Growing evidence suggests that elevated HA is associated with attentional bias (AB) toward potential health-threat information.

DESIGN

This study aimed to examine the effects of attention retraining among individuals with elevated HA, using the established attention modification programs (AMP) designed to train participants to disengage attention from ideographically chosen health-threat words.

METHODS

Thirty-six randomly assigned individuals with elevated HA completed eight twice-weekly sessions of the AMP (n = 18) or the attention control condition (ACC; n = 18).

RESULTS

Despite using the well-established AMP protocol widely used within the field of anxiety disorders, we did not find evidence for change in AB following training. Further, AMP did not outperform ACC in reducing HA and other relevant emotional symptoms. However, both AMP and ACC evidenced overall significant symptom reduction in most of the outcome measures, including overall HA, anxiety sensitivity, general depression and anxiety, and somatic complaints.

CONCLUSIONS

Further research is needed to better understand the effects and mechanisms of AMP as a possible cognitive intervention for HA.

Health-related internet habits and health anxiety in university students

Health-related Internet use has grown rapidly, yet little research has considered how health anxious individuals use the Internet for this purpose. Our aim was to examine the relationships between health anxiety and the extent of, reasons for, and consequences of health-related Internet usage in university students (n = 255). Responses on a purpose-made Internet use questionnaire were correlated with health anxiety scores; multiple regression analyses controlling for depression and anxiety were also conducted. Health anxiety positively correlated with (all ps < .01): frequency of health-related searching (r(s) = .163), proportion of health-related information sought (r(s) = .200), time spent online for health purposes (r(s) = .166), and number of searches for both illness (r(s) = .453) and wellness (r(s) = .208) information. Health anxiety further positively correlated with advantages perceived in health-related Internet use (r(s) = .183), heightened tension (r(s) = .364) and relief (r(s) = .174) post-search, and perceived doctor disadvantages (r(s) = .306), yet a greater likelihood to visit a doctor post-search (r(s) = .217). Health anxiety also correlated with six measures of possible addiction to using the Internet for health purposes (r(s) range = .171 to .366, all ps < .01). Some (including several potentially dysfunctional) aspects of health-related Internet use correlate with health anxiety. Research evaluating the possible role of Internet use in the development and maintenance of health anxiety is warranted.

A behavioral test of contamination fear in excessive health anxiety

BACKGROUND AND OBJECTIVES

Health anxiety is characterized by a preoccupation with the possibility of having a serious health condition or disease. Contemporary conceptualizations of health anxiety have improved in recent years to incorporate a fear of acquiring an illness; however, there is limited experimental data demonstrating the presence of fear of contamination among health anxious individuals.

METHOD

The present study utilized behavior approach tasks (BATs) to examine the degree to which contamination fear is present in elevated health anxiety. Participants were 60 undergraduate students who reported elevated health anxiety, contamination fear, or no anxiety about either health or contamination. Participants completed four BATS from which avoidance, anxiety, and disgust ratings were derived.

RESULTS

Health anxious and contamination fearful individuals exhibited a similar degree of avoidance during the BATs. Contamination fearful participants reported significantly more anxiety and disgust relative to the non-anxious controls, but not the health anxious participants. Health anxious participants did not report more anxiety or disgust than the non-anxious participants.

LIMITATIONS

The use of an analogue sample may limit the extension of these findings to clinical populations. Additionally, the role of general negative affect could not be reliably determined in the absence of an anxious control group.

CONCLUSIONS

These findings suggest that contamination fear may be a source of conceptual overlap between health anxiety and other disorders characterized by contamination fear. This highlights the importance of considering contamination fear in excessive health anxiety.

Family background of modern health worries, somatosensory amplification, and health anxiety: A questionnaire study

In the development of somatosensory amplification, health anxiety, and modern health worries, environmental factors seem more important than genetic background. Parental attitudes might represent a major source of learning. In total, 186 adolescents and their parents completed a questionnaire assessing modern health worries, somatosensory amplification, health anxiety, and somatic symptoms. Adolescents’ modern health worries, somatosensory amplification, and health anxiety were positively related to respective parental characteristics in regression analyses even after controlling for sociodemographic variables and somatic symptoms. Parental beliefs may play a role in the development of these characteristics.

Health anxiety and healthcare costs in Japanese individuals: an Internet survey

Aim: Health anxiety, also known as hypochondriasis, is classifiable as an anxiety disorder. The aim of this study was to examine the relationship between health anxiety and healthcare costs. Method: Participants - 100 Japanese individuals from the general population with chronic health problems and 100 without chronic health problems - were recruited via the Internet. They completed self-report scales measuring health anxiety, state anxiety, depression, obsessionality, and a scale specifically developed for this study that measured the use of healthcare services and the personal costs of respondents' healthcare. Results: Health anxiety was associated with more incidents of inpatient care and greater healthcare expenditure. These associations remained significant even after controlling for state anxiety, depression, obsessionality, and the presence of chronic health problems. Conclusion: We conclude that health anxiety is related to personal as well as social costs in Japan.

Short Health Anxiety Inventory: Factor structure and psychometric properties in Spanish adolescents

The Short Health Anxiety Inventory is a common screening tool for assessing health anxiety among adolescents; however, its psychometric properties and internal structure have not been evaluated within a Spanish-speaking population. The goodness of fit of four models of the latent structure of the Short Health Anxiety Inventory was tested by using confirmatory factor analysis in a sample of 832 Spanish secondary school adolescents. Based on these results, the reliability of the original two-factor model was tested. Differences in health anxiety by gender and age were also examined. The results support use of the Spanish version of the Short Health Anxiety Inventory by researchers and clinicians among Spanish adolescents.

Perceptions of health and somatic sensations in women reporting premenstrual syndrome and premenstrual dysphoric disorder

Focus on bodily sensations may be involved in the etiology of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). This study investigated the relationship between two types of somatic self-focus (i.e., health anxiety and anxiety sensitivity) and health-related quality of life (QOL) in women with provision diagnoses of PMS and PMDD. On the basis of responses to a screening measure, 731 college women were divided into three groups: PMDD, Moderate/Severe PMS, and Mild/No PMS. Measures included health-related QOL, health anxiety, anxiety sensitivity, and trait anxiety. Women with provisional diagnoses of PMDD and moderate/severe PMS reported higher levels of health anxiety and anxiety sensitivity. These relationships were not accounted for by trait anxiety. Furthermore, women in the PMDD and Moderate/Severe PMS groups reported lower health-related QOL. There is a significant health-related QOL burden for college women with PMDD and PMS. Health anxiety and anxiety sensitivity may contribute to the etiology of premenstrual disorders.

Cyberchondria and intolerance of uncertainty: examining when individuals experience health anxiety in response to Internet searches for medical information

Individuals frequently use the Internet to search for medical information. However, for some individuals, searching for medical information on the Internet is associated with an exacerbation of health anxiety. Researchers have termed this phenomenon as cyberchondria. The present research sought to shed further light onto the phenomenology of cyberchondria. In particular, the moderating effect of intolerance of uncertainty (IU) on the relationship between the frequency of Internet searches for medical information and health anxiety was examined using a large sample of medically healthy community adults located in the United States (N=512). The purported moderating effect of IU was supported. More specifically, the relationship between the frequency of Internet searches for medical information and health anxiety grew increasingly stronger as IU increased. This moderating effect of IU was not attributable to general distress. These results suggest that IU is important for better understanding the exacerbation of health anxiety in response to Internet searches for medical information. Conceptual and therapeutic implications of these results are discussed.

The Short Health Anxiety Inventory: a systematic review and meta-analysis

INTRODUCTION

The Short Health Anxiety Inventory (SHAI) measures health anxiety in medical and non-medical contexts.

OBJECTIVE

To review the literature pertaining to the psychometric properties of the SHAI in non-clinical, clinical, and medical samples. Meta-analysis was also conducted to examine the strength of associations between the SHAI and other constructs.

METHODS

Direct search of digital databases for papers that cited the original SHAI publication.

RESULTS

Seventy-eight papers were identified, with 42 providing relevant information. The SHAI has acceptable Cronbach's alpha scores, strong construct validity, and is sensitive to treatment. Discrepancies have been observed between the findings of factor analytic studies, largely as a result of varying methods used. Overall, there appears to be greatest support for the original two factors, with one factor assessing health anxiety and one factor assessing negative consequences of illness. As expected, individuals with hypochondriasis score higher as compared to non-clinical samples. The strongest association was observed between the SHAI and other measures of health anxiety, followed by measures related to health anxiety vulnerability, and then general anxiety and worry.

CONCLUSIONS

The SHAI is a psychometrically sound tool for assessing health anxiety across samples. Future studies are needed, however, to assess test-retest reliability, incremental validity, and cut-off scores as well as use of the SHAI among diverse samples.

Attentional bias toward personally relevant health-threat words

Conflicting findings have emerged regarding the presence of attentional biases (ABs) in health anxiety, probably due to methodological limitations in the stimuli used in cognitive tasks and the assessment of health anxiety-relevant factors. The current study sought to examine ABs toward health-related threats using idiographically chosen health-threat words in a non-clinical sample. A modified dot-probe task using idiographically selected health-threat words was administered to an undergraduate sample. Self-report measures were administered to assess somatic, cognitive, and behavioral aspects of health anxiety, in addition to assessing negative affect, anxiety sensitivity, and experience of actual medical conditions. Results showed that behavioral and somatic aspects of health anxiety were significantly associated with AB toward personally relevant threat words, even after controlling for negative affect, anxiety sensitivity, and experience of actual medical conditions. Additional analyses revealed that these biases reflected difficulty disengaging attention from threat rather than a facilitated detection of threat. In contrast, illness-related cognitions were found to be unrelated to ABs. These findings suggest an association between threat-related ABs and excessive health-care seeking efforts.

The association between health anxiety and disgust reactions in a contamination-based behavioral approach task

Existing evidence suggests that disgust is an important affective process related to health anxiety. The present study sought to determine the contribution of health anxiety symptoms in the prediction of disgust and behavioral avoidance in a large, nonclinical sample (N=156). Regression analyses showed that overall health anxiety symptoms predicted disgust on a behavioral approach task independent of gender, negative affect, and fear of contamination. Particularly, health anxiety-related reassurance seeking was found to be uniquely associated with disgust and behavioral avoidance after controlling for the aforementioned covariates. In addition, the interaction between health anxiety and contamination fear was tested, and remained significant when controlling for gender and negative affect. These results suggest that heightened contamination fear is associated with elevated disgust reactions such that high levels of health anxiety leads even those low in contamination fear to be disgusted during a behavioral task. These results are in line with previous research on the role of disgust in health anxiety.

Dimensions of anxiety sensitivity in the anxiety disorders: evaluation of the ASI-3

Anxiety sensitivity (AS), the fear of sensations of anxious arousal based on beliefs about their harmful consequences, is increasingly recognized as a multidimensional construct. The recently developed Anxiety Sensitivity Index-3 [ASI-3; Taylor, S., Zvolensky, M., Cox, B., Deacon, B., Heimberg, R., Ledley, D. R., et al. (2007). Robust dimensions of anxiety sensitivity: Development and initial validation of the Anxiety Sensitivity Index-3 (ASI-3). Psychological Assessment, 19, 176-188] measures three dimensions of AS: physical concerns, social concerns, and cognitive concerns. The ASI-3 shows promise, although further evaluation of its psychometric properties and validity in independent samples is needed. We evaluated the ASI-3 in a mixed sample of anxiety disorder patients (N=506) and undergraduate student controls (N=315). The measure demonstrated a stable 3-factor structure and sound psychometric properties, with the three factors showing theoretically consistent patterns of associations with anxiety symptoms and diagnoses. ASI-3 total scores were less discriminative. Implications for conceptual models of anxiety are discussed.

The Affective and Cognitive Dimensions of Health Anxiety Are Associated With Different Orientations to Health Threat

Using a sample of medically healthy college students (N = 412), this study examined whether the two core dimensions of health anxiety share differential relations with orientations (approach and avoidance) to health threat. These two dimensions are an affective dimension marked by health worry and a cognitive dimension marked by disease conviction. Using a scenario-based measure that depicted potential health threats, the tendency to respond to such threats using safety behaviors that paralleled either approach or avoidance behavior was assessed. As predicted, zero-order and partial correlation analyses revealed that approach-based safety behaviors were especially relevant to the affective dimension of health anxiety and avoidance-based safety behaviors were especially relevant to the cognitive dimension of health anxiety. Conceptual and therapeutic implications are discussed.

Cyberchondriasis: fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet

This study examined the relationship between health anxiety and searching for health information online, a phenomenon dubbed 'cyberchondria'. The majority of those with 'high' (n=46) and 'low' (n=36) levels of health anxiety reported seeking health information online. However, those with higher levels of health anxiety sought online health information more frequently, spent longer searching, and found searching more distressing and anxiety provoking. Furthermore, more responses in the high than low health anxiety group related to searching for information on diagnosed and undiagnosed medical conditions, descriptions of others' experiences of illnesses and using message boards/support groups, although the largest proportion of responses in both groups was accounted for by seeking information on symptoms. Linear regression (n=167) revealed significant relationships between health anxiety and the frequency, duration and distress and anxiety associated with searching for health information online. This preliminary data suggests that searching for health information online may exacerbate health anxiety.

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

The present study examined the extent to which safety behaviors exacerbate symptoms of hypochondriasis (severe health anxiety). Participants were randomized into a safety behavior (n=30) or control condition (n=30). After a baseline period, participants in the safety behavior condition spent one week actively engaging in a clinically representative array of health-related safety behaviors on a daily basis, followed by a second week-long baseline period. Participants in the control condition monitored their normal use of safety behaviors. Compared to control participants, those in the safety behavior condition reported significantly greater increases in health anxiety, hypochondriacal beliefs, contamination fear, and avoidant responses to health-related behavioral tasks after the safety behavior manipulation. In contrast, general anxiety symptoms did not significantly differ between the two groups as a function of the manipulation. Mediational analyses were consistent with the hypothesis that changes in the frequency of health-related thoughts mediated the effects of the experimental manipulation on health anxiety. These findings suggest that safety behaviors are associated with increases in health anxiety, perhaps by fostering catastrophic thoughts about health. The implications of these findings for the conceptualization of hypochondriasis as an anxiety disorder are discussed.

Health anxiety: comparison of the latent structure in medical and non-medical samples

The Short Health Anxiety Inventory (SHAI; Salkovskis, Rimes, Warwick, & Clark, 2002) is a self-report measure designed to assess health anxiety in both medical and non-medical samples. The invariance of the factor structure across these samples has not been examined in the 14-item version of the SHAI. In the current study, the SHAI was completed by a community sample with no serious medical conditions (n=232) and a medical sample with multiple sclerosis (n=245). Factor analysis implied the same two-factor solution for both samples, with the two factors labelled: (1) Thought Intrusion, and (2) Fear of Illness. Item loadings were invariant across the medical and non-medical samples, but the two factors were more strongly correlated in the non-medical sample. Implications of the findings as well as directions for future research are discussed.

Disease phobia and disease conviction are separate dimensions underlying hypochondriasis

The current study uses data from a large nonclinical college student sample (N = 503) to examine a structural model of hypochondriasis (HC). This model predicts the distinctiveness of two dimensions (disease phobia and disease conviction) purported to underlie the disorder, and that these two dimensions are differentially related to variables important to health anxiety and somatoform disorders, respectively. Results were generally consistent with the hypothesized model. Specifically, (a) body perception variables (somatosensory amplification and anxiety sensitivity - physical) emerged as significant predictors of disease phobia, but not disease conviction; (b) emotion dysregulation variables (cognitive avoidance and cognitive reappraisal) emerged as significant predictors of disease conviction, but not disease phobia; and (c) both disease phobia and disease conviction independently predicted medical utilization. Further, collapsing disease phobia and disease conviction onto a single latent factor provided an inadequate fit to the data. Conceptual and therapeutic implications of these results are discussed.

Health anxiety among older people: an exploratory study of health anxiety and safety behaviors in a cohort of older adults in New Zealand

BACKGROUND

Despite a stereotype that characterizes older people as excessively anxious about their health, there is little research into this phenomenon. The present exploratory study examined: (a) whether a cohort of older adults was unduly health anxious, (b) which demographic and health factors predicted health anxiety (HA), and (c) whether an aspect of the cognitive behavioral model of HA was applicable to older adults by investigating the relationship between HA and safety behaviors.

METHOD

Participants were a convenience sample of adults aged over 65 and living independently in Auckland, New Zealand. Participants (104 women and 41 men) completed an anonymous self-report questionnaire measuring demographic factors, physical health and function, health anxiety, safety behaviors, and medical utilization.

RESULTS

This cohort of adults over 65 were not unduly health anxious. Occurrence of severe HA was similar to that found in younger populations. Decreased physical function and lower education predicted scores on the HA measure. Consistent with the cognitive behavioral model, HA was a unique significant predictor of safety behaviors. HA and decreased physical function predicted medical utilization.

CONCLUSIONS

Generally low levels of HA among this cohort of older individuals challenged the pervasive stereotype of the "hypochondriacal" older person. Factors contributing to HA were similar to those reported in studies with younger cohorts. Findings provided preliminary support for the applicability of the cognitive behavioral model of HA to adults over 65. Implications of the findings and directions for future research were discussed.

Die Bedeutung von Ekel- und Angstsensitivität bei Personen mit der Verdachtsdiagnose einer Hypochondrie

Zentrales Merkmal bei der hypochondrischen Störung ist die Befürchtung, an einer schweren Erkrankung zu leiden. Dies führt zur Fehlinterpretation normaler Körperfunktionen. Neben dysfunktionalen Angstzuständen ist auch stark ausgeprägte Angstsensitivität störungsrelevant. Das aktuelle Hypochondriekonzept ist vorwiegend angstfokussiert, während die Bedeutung anderer Emotionen wie zum Beispiel von Ekel bisher kaum untersucht wurde. Ziel dieser Untersuchung war es herauszufinden, ob die habituelle Ekelneigung einen zusätzlichen Prädiktor für die Vorhersage von Hypochondrie darstellt. Nach einem Screening mit einem standardisierten klinischen Interview wurden 27 Personen mit und 27 Personen ohne Verdachtsdiagnose Hypochondrie in die Studie eingeschlossen und getestet. Mittels Diskriminanzanalyse wurde überprüft, ob Ekelempfindlichkeit (Neigung einer Person, mit Ekel zu reagieren) und Ekelsensitivität (Neigung, Ekelempfindungen als bedrohlich zu bewerten) für die Gruppentrennung in Personen mit und ohne Verdachtsdiagnose Hypochondrie (Kriterium: Whitely Index) relevant sind. Es zeigte sich, dass habituelle Angst, Ekelsensitivität und spezifische Bereiche der Ekelempfindlichkeit (z. B. Abneigung vor mangelhafter Hygiene) zwischen den beiden Gruppen differenzierten. Domänenspezifische Beziehungen zwischen Ekelempfindlichkeit und Hypochondrie werden diskutiert.

Reexamining the domain of hypochondriasis: comparing the Illness Attitudes Scale to other approaches

The present study examined utility of the Illness Attitudes Scale (IAS; [Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger Publishers]) in a non-clinical college sample (N=235). Relationships among five recently identified IAS dimensions (fear of illness and pain, symptom effects, treatment experience, disease conviction, and health habits) and self-report measures of several anxiety-related constructs (health anxiety, body vigilance, intolerance of uncertainty, anxiety sensitivity, and non-specific anxiety symptoms) were examined. In addition, this study investigated the incremental validity of the IAS dimensions in predicting medical utilization. The fear of illness and pain dimension and the symptom effects dimension consistently shared stronger relations with the anxiety-related constructs compared to the other three IAS dimensions. The symptom effects dimension, the disease conviction dimension, and the health habits dimension showed incremental validity over the anxiety-related constructs in predicting medical utilization. Implications for the IAS and future conceptualizations of HC are discussed.

Incremental specificity of disgust propensity and sensitivity in the prediction of health anxiety dimensions

The present study sought to determine the incremental specificity of disgust propensity and sensitivity in the prediction of symptoms of health anxiety in a large nonclinical sample (N=498). Exploratory factor analysis identified Illness Likelihood, Illness Severity, and Body Vigilance as dimensions of health anxiety symptoms that significantly correlated with disgust propensity and sensitivity. Negative affect and the fear of contamination were also significantly correlated with the three health anxiety symptom dimensions. Regression analyses did show that disgust propensity and sensitivity predicted overall health anxiety symptoms independent of negative affect and fear of contamination. However, the unique association between disgust propensity and sensitivity and symptoms of health anxiety was specific to the Body Vigilance dimension. These findings suggest that disgust propensity and sensitivity may be a unique vulnerability for the vigilance for bodily sensations/changes aspect of health anxiety but not necessarily other (perceived probability/severity of having a serious illness) aspects of health anxiety. The clinical and research implications of these findings for conceptualizing disgust propensity and sensitivity as a vulnerability for excessive health anxiety are discussed.

Is hypochondriasis an anxiety disorder?

Although hypochondriasis is currently classified as a somatoform disorder, the underlying cognitive processes may be more consistent with an anxiety disorder. This observation has important implications for treatment and subsequent revisions of the diagnostic classification of hypochondriasis.