Attribution of somatic symptoms in hypochondriasis

Mechanistic studies in pathological health anxiety: A systematic review and emerging conceptual framework

BACKGROUND

Pathological health anxiety (PHA) (e.g., hypochondriasis and illness anxiety disorder) is common in medical settings and associated with increased healthcare costs. However, the psychological and neurobiological mechanisms contributing to the development and maintenance of PHA are incompletely understood.

METHODS

We performed a systematic review to characterize the mechanistic understanding of PHA. PubMed, PsycINFO, and Embase databases were searched to find articles published between 1/1/1990 and 12/31/2022 employing a behavioral task and/or physiological measures in individuals with hypochondriasis, illness anxiety disorder, and PHA more broadly.

RESULTS

Out of 9141 records identified, fifty-seven met inclusion criteria. Article quality varied substantially across studies, and was overall inadequate. Cognitive, behavioral, and affective findings implicated in PHA included health-related attentional and memory recall biases, a narrow health concept, threat confirming thought patterns, use of safety-seeking behaviors, and biased explicit and implicit affective processing of health-related information among other observations. There is initial evidence supporting a potential overestimation of interoceptive stimuli in those with PHA. Neuroendocrine, electrophysiology, and brain imaging research in PHA are particularly in their early stages.

LIMITATIONS

Included articles evaluated PHA categorically, suggesting that sub-threshold and dimensional health anxiety considerations are not contextualized.

CONCLUSIONS

Within an integrated cognitive-behavioral-affective and predictive processing formulation, we theorize that sub-optimal illness and health concepts, altered interoceptive modeling, biased illness-based predictions and attention, and aberrant prediction error learning are mechanisms relevant to PHA requiring more research. Comprehensively investigating the pathophysiology of PHA offers the potential to identify adjunctive diagnostic biomarkers and catalyze new biologically-informed treatments.

Prevalence and associated factors of health anxiety in patients with temporomandibular disorders

OBJECTIVES

To investigate the prevalence and associated factors of health anxiety (HA) in patients with Temporomandibular Disorders (TMDs) using the 8-item Whiteley Index (WI-8) scale.

MATERIALS AND METHODS

Three hundred and twenty-nine TMDs patients completed the Visual Analog Scale (VAS), WI-8, Jaw Functional Limitation Scale-8 (JFLS-8), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7) scales. Clinical examinations were conducted following the Diagnostic Criteria for TMDs Axis I.

RESULTS

The prevalence of HA among TMDs patients was 18.54%. Patients with HA had higher scores of VAS-current (p = 0.026), VAS-maximum (p = 0.024), VAS-average (p = 0.030), JFLS-8 (p < 0.001), GAD-7 (p < 0.001) and PHQ-9 (p < 0.001), lower maximum mouth opening (p = 0.016), lower proportion of structure-related TMDs (p = 0.028), and higher proportion of pain-related TMDs (p < 0.001) compared to those without HA. The correlation coefficient was 0.61 (p < 0.001) between WI-8 and GAD-7 and 0.64 (p < 0.001) between WI-8 and PHQ-9.

CONCLUSION

Approximately one-fifth of patients with TMDs experienced HA. HA was associated with pain perception, functional limitations, depressive, and anxiety symptoms in individuals with TMDs. HA may contribute to heightened subjective pain experiences rather than structural changes in the TMJ.

Transdiagnostic cognitive biases in psychiatric disorders: A systematic review and network meta-analysis

Psychiatric disorders are characterized by cognitive deficits, which have been proposed as a transdiagnostic feature of psychopathology ("C" factor). Similarly, cognitive biases (e.g., in attention, memory, and interpretation) represent common tendencies in information processing that are often associated with psychiatric symptoms. However, the question remains whether cognitive biases are also transdiagnostic or are specific to certain psychiatric disorders/symptoms. The current systematic review sought to address whether the proposed "C" factor of transdiagnostic cognitive dysfunction in psychopathology can be extended to cognitive biases. Overall, 31 studies comprising 4401 participants (2536 patients, 1865 non-clinical controls) met inclusion criteria, assessing 19 cognitive biases across 20 diagnostic categories, with most studies focusing on interpretation (k = 22) and attention (k = 11) biases and only 2 assessing memory biases. Traditional meta-analyses found a moderate effect size (g = 0.32) for more severe cognitive biases in all patients relative to non-clinical controls, as well as small but significant associations between interpretation biases and transdiagnostic symptom categories (general psychopathology: r = 0.20, emotion dysfunction: r = 0.17, psychotic symptoms: r = 0.25). Network meta-analyses revealed significant patient versus non-clinical control differences on attention and interpretation biases across diagnoses, as well as significant differences between diagnoses, with highest severity in panic disorder for attention biases and obsessive-compulsive disorder for interpretation biases. The current findings extend the big "C" interpretation of transdiagnostic cognitive dysfunction in psychiatric disorders to cognitive biases and transdiagnostic symptom dimensions. Results also suggest that while the presence of cognitive biases is transdiagnostic, bias severity differs across diagnoses, as in traditional neurocognitive deficits.

Respiratory Interoception and Pathological Illness Anxiety: Disentangling Bias

OBJECTIVE

Biased interoception decoupled from physiology might be relevant in the etiology of pathological illness anxiety (PIA). Empirical evidence for interoceptive deviations in illness anxiety is scarce but potentially informative to optimize treatments. We hypothesized that persons with PIA differ fundamentally in the classification of bodily sensations from those without PIA.

METHODS

In a respiratory categorization task, participants breathed into a pulmonary training device. Inspiration effort was varied by eight resistive loads. The lower/higher four loads were introduced as belonging to arbitrary categories "A"/"B," respectively. Participants memorized respiratory sensations in a first experimental block and were asked to label the resistances in a second block. We calculated the sensitivity of resistance classification according to category and response bias in terms of categorical misclassification. Data of 39 participants with PIA and 35 controls were compared with regard to sensitivity and response bias by group, resistive load, and their interaction in a multiple regression.

RESULTS

With similar sensitivity, patients more often labeled loads above the categorical border erroneously as belonging to category A, thus underestimating their resistance ( β = -0.06, p = .001; η2 = 0.02).

CONCLUSIONS

Individuals with PIA showed a systematic "wait and see" approach. Altered respiroception in PIA might stem from biased perception during training phase, the recognition phase, biased memory, or a combination of these. Its exact characteristics remain unknown, and future research must address the challenge of developing reliable and valid paradigms accounting for the variability of interoceptive biases.

REGISTRATION

This work was preregistered on OSF ( https://osf.io/9shcw ).

The relationship between maladaptive health beliefs, pandemic-related stress, and health anxiety during the COVID-19 pandemic

BACKGROUND

Research has demonstrated that people experience specific distress and anxiety regarding COVID-19. This distress may consist of interconnected symptom categories corresponding to a COVID stress syndrome. Susceptibility to COVID stress syndrome may be related to one's maladaptive health beliefs; however, no research has investigated the association between maladaptive health beliefs and COVID stress. The present study explored the impact of health beliefs on COVID stress, health anxiety, and associated psychological constructs.

PARTICIPANTS AND PROCEDURE

This cross-sectional survey study included 221 adults (M age = 20.59, SD = 2.28). Participants completed an online survey including demographic questionnaires and self-report measures of health beliefs, COVID stress, health anxiety, and related psychological constructs.

RESULTS

Health anxiety, anxiety sensitivity, state/trait anxiety, intolerance of uncertainty, and depression accounted for significant variance in COVID stress (F(6, 214) = 11.18, R2 = .24, p < .001). Health beliefs (i.e., perceived likelihood of illness, medical service inadequacy, and difficulty coping) were associated with greater COVID stress, although health beliefs were not found to mediate the relationship between health anxiety and COVID stress.

CONCLUSIONS

Health beliefs were associated with greater COVID stress, although health beliefs did not mediate the relationship between health anxiety and COVID stress. The relationship between health anxiety and COVID stress may be better explained by other COVID-related cognitions (e.g., vaccine efficacy, dangerousness of COVID-19). The findings highlight the importance of peoples' health beliefs during the pandemic. Given anxiety's influence on peoples' behavioural responses to the pandemic, further research should identify COVID-specific cognitions for prevention of COVID stress and health anxiety.

Interpretation bias in health anxiety: a systematic review and meta-analysis

Interpretation bias (i.e. the selective negative interpretation of ambiguous stimuli) may contribute to the development and maintenance of health anxiety. However, the strength of the empirical evidence for this association remains a topic of debate. This study aimed to estimate the association between health anxiety and interpretation bias and to identify potential moderators of this association. Chinese-language databases (CNKI, VIP, and Wanfang), English-language databases (Web of Science, PubMed, PsycINFO, and Scopus), and German-language databases (Psyndex and PubPsych) were searched for relevant studies. There were 36 articles (39 studies) identified by this search (N = 8984), of which 32 articles (34 studies) were included in the meta-analysis (N = 8602). Results revealed a medium overall effect size (g = 0.67). Statistically equivalent effect sizes were observed for patients diagnosed with clinical health anxiety (g = 0.58) and subclinical health anxiety (g = 0.72). The effect sizes for threat stimuli that were health related (g = 0.68) and not health related (g = 0.63) did not differ significantly. The effect size for studies using an offline paradigm (g = 0.75) was significantly higher than that for studies using an online paradigm (g = 0.50). It is concluded that health anxiety is significantly and robustly associated with interpretation bias. These findings are of central importance for the advancement of models and treatment of health anxiety.

Do patients with pathological health anxiety fear COVID-19? A time-course analysis of 12 single cases during the "first wave" of the COVID-19 pandemic in Germany

OBJECTIVE

Pre-existing health anxiety is associated with an intensified affective response to the novel COVID-19 pandemic in the general population. Still, results on the reaction of people with a diagnosis of pathological health anxiety (i.e., hypochondriasis) are scarce.

METHODS

In the present study, we investigated the course of (health) anxiety related to SARS-CoV-2/COVID-19 in comparison to (health) anxiety related to other severe diseases (e.g., cancer) in a sample of 12 patients with the diagnosis of pathological health anxiety during the "first wave" of the COVID-19 pandemic in Germany. Both SARS-CoV-2 related anxiety and anxiety related to other severe diseases were assessed weekly over 16 measurement points (30.03.-19.07.2020) and primarily analyzed with fixed effects regression analyses.

RESULTS

Unexpectedly, SARS-CoV-2 related anxiety was on average significantly lower than anxiety related to other severe diseases (d = -0.54, p < .001) and not significantly associated with anxiety related to other severe diseases or pre-COVID-19 health anxiety.

CONCLUSION

It therefore appears premature to assume that SARS-CoV-2 related anxiety and other health worries are necessarily strongly interrelated and comparably high in people with pathological health anxiety.

Increased Frequency of Health Anxiety in Health Science Students: a Cross Sectional Study in a Greek University

Background:

Ectopic Health Sciences students often experience higher level of stress due to clinical knowledge, and it has been reported that they frequently develop worries and symptoms of illness. These observations had lead to the hypothesis that studying health sciences may increase the risk for developing health anxiety.

Objective:

To investigate the correlation between studying health sciences and health anxiety risk in students of a Greek university.

Methods:

A cross-sectional study was conducted among health science and non-health science students from the University of Thessaly, Greece. The 14 item - Short Health Anxiety Inventory (SHAI) was used to measure students’ health anxiety. Univariable and multivariable logistic regression analyses were used to test the hypothesis.

Results:

The population sample consisted of 562 health science students and 204 agriculture and computer science students. The prevalence of health anxiety (SHAI score >14) was 18.1% (95% CI 15.4%-21.1%) while 8.3% (95% CI 6.4%-10.5%) of the participants suffered from clinical health anxiety (SHAI score >18). Health science students had higher SHAI scores compared to non-health science students. Multivariable analysis revealed an increased risk for health anxiety in health science students (OR: 2.01, 95% CI: 1.02-3.97, p=0.044). Health anxiety was also associated with sex (female) (p<0,008) and the presence of health anxiety in a family member (p<0,001).

Conclusion:

The current study identified studying health sciences as a determinant of health anxiety in students of a Greek university, after considering several confounding factors. This relatively neglected hypothesis should be further examined, preferably in a prospective cohort design.

Psychometric Properties of the Korean Version of the Patient Knowledge Questionnaire-Osteoarthritis

This study examined the psychometric properties of the Korean version of the Patient Knowledge Questionnaire-Osteoarthritis (PKQ-OA-K). A cross-sectional survey was conducted with 157 adults with osteoarthritis from the outpatient clinic at a university hospital in Korea. The overall correct answer rate for the PKQ-OA-K was 60.4%; notably, the drug therapy subscale had the lowest median score percentage (42.9%). For structural validity, exploratory factor analysis identified the PKQ-OA-K as two-dimensional, explaining 52.4% of the total variance. Confirmatory factor analysis showed that the two-factor model adequately fit the data. The PKQ-OA-K was positively correlated with education level (r = 0.24) and osteoarthritis outcomes (r = 0.17), thus verifying the hypotheses of construct validity. The intraclass correlation coefficient for test-retest reliability was 0.52; alpha was 0.44. The PKQ-OA-K has excellent validity but imperfect reliability for adults with osteoarthritis. This study recommends cautious use of the PKQ-OA-K to assess Korean patients' knowledge of osteoarthritis.

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.

Symptomatology differences of major depression in psychiatric versus general hospitals: A machine learning approach

BACKGROUND

Symptomatology differences of major depressive disorder (MDD) in psychiatric and general hospitals in China leads to possible misdiagnosis. Looking at the symptomatology of first-visit patients with MDD in different mental health services, and identifying predictors of health-seeking behavior using machine learning may help to improve diagnostic accuracy.

METHODS

1500 patients first diagnosed with MDD were recruited from 16 psychiatric hospitals and 16 general hospitals across China. Socio-demographic characteristics, causal attribution, symptoms of depression within and outside Diagnostic and Statistical Manual of Mental Disorders (DSM) framework were collected using a self-made questionnaire. A predictive model of 62 variables was established using Random forest, symptom frequencies of patients in general hospitals and psychiatric hospitals were compared.

RESULTS

The machine learning approach revealed that symptoms were strong predictors of health-seeking behavior among patients with MDD. General hospitals patients had higher frequencies of suicidal ideation (χ²=15.230, p<0.001), psychosis (χ²=14.264, p<0.001), weight change (all p<0.001), hypersomnia (χ²=25.940, p<0.001), and a tendency of denying emotional/cognitive symptoms compared with psychiatric hospitals patients.

LIMITATIONS

Stigma and preference bias were not measured. Severity of current depressive episodes was not assessed. Data of previous episode(s) was not presented.

CONCLUSIONS

Symptom evaluation targeting specific patient population in different hospitals is crucial for diagnostic accuracy. Suicide prevention reliant on collaboration between general hospitals and psychiatric hospitals is required in the future construction of Chinese mental health system.

Hypochondriac concerns and correlates of personality styles and affective states in bipolar I and II disorders

BACKGROUND

Hypochondriac concerns are associated with the treatment-difficulty of bipolar disorder, which might be due to the personality styles and affective states.

METHODS

We invited outpatients with bipolar I disorder (BD I, n = 87), bipolar II disorder (BD II, n = 92) and healthy volunteers (n = 129) to undergo the Illness Attitude Scales and Parker Personality Measure tests, and measurements of concurrent affective states.

RESULTS

Compared to healthy volunteers, BD I and BD II patients scored significantly higher on mania, hypomania and depression. BD I and BD II patients also scored significantly higher on Symptom Effect and Treatment Seeking, and BD II patients scored higher on Patho-thanatophobia and Hypochondriacal Belief. BD II in addition scored higher on Patho-thanatophobia than BD I did. In controls, the Dependent style predicted Patho-thanatophobia and Symptom Effect, Schizoid with Hypochondriacal Belief; in BD I, Narcissistic (-) with Hypochondriacal Belief, Histrionic with Patho-thanatophobia and Hypochondriacal Belief, depression with Hypochondriacal Belief, and hypomania with Symptom Effect and Hypochondriacal Belief; in BD II, depression with Symptom Effect and Hypochondriacal Belief, mania with Symptom Effect.

CONCLUSIONS

Bipolar disorder, especially BD II, is associated with greater hypochondriac concerns, which relates to personality disorder functioning styles and concurrent affective states.

How do illness-anxious individuals process health-threatening information? A systematic review of evidence for the cognitive-behavioral model

According to the cognitive-behavioral model, illness anxiety is developed and maintained through biased processing of health-threatening information and maladaptive responses to such information.

OBJECTIVE

This study is a systematic review of research that attempted to validate central tenets of the cognitive-behavioral model regarding etiological and maintenance mechanisms in illness anxiety.

METHODS

Sixty-two studies, including correlational and experimental designs, were identified through a systematic search of databases and were evaluated for their quality.

RESULTS

Outcomes were synthesized following a qualitative thematic approach under categories of theoretically driven mechanisms derived from the cognitive-behavioral model: attention, memory and interpretation biases, perceived awareness and inaccuracy in perception of somatic sensations, negativity bias, emotion dysregulation, and behavioral avoidance.

CONCLUSIONS

Findings partly support the cognitive-behavioral model, but several of its hypothetical mechanisms only receive weak support due to the scarcity of relevant studies. Directions for future research are suggested based on identified gaps in the existing literature.

Predictors and consequences of health anxiety symptoms: a novel twin modeling study

OBJECTIVE

The question of how to best conceptualize health anxiety (HA) from a diagnostic and etiological perspective remains debated. The aim was to examine the relationship between HA and the symptoms of anxiety and obsessive-compulsive-related disorders in a normative twin population.

METHOD

Four hundred and ninety-six monozygotic adult twin pairs from the Australian Twin Registry participated in the study (age, 34.4 ± 7.72 years; 59% females). Validated scales were used to assess each domain. We applied a twin regression methodology-ICE FALCON-to determine whether there was evidence consistent with 'causal' relationships between HA and other symptoms by fitting and comparing model estimates.

RESULTS

Estimates were consistent with higher levels of obsessing ('unwanted thoughts') (P = 0.008), social anxiety (P = 0.03), and body dysmorphic symptoms (P = 0.008) causing higher levels of HA symptoms, and with higher levels of HA symptoms causing higher levels of physical/somatic anxiety symptoms (P = 0.001).

CONCLUSION

Obsessional thoughts, body dysmorphic concerns, and social anxiety symptoms may have a causal influence on HA. To report physical/somatic anxiety appears to be a consequence of the underlying presence of HA-related fears. Should our results be confirmed by longitudinal studies, the evaluation and treatment of HA may benefit from the consideration of these identified risk factors.

Health anxiety and medical utilization: The moderating effect of age among patients in primary care

Health anxiety is commonly seen in medical clinics and is related to the overutilization of primary care services, but existing studies have not yet considered the possible moderating effect of age. We examined if age moderated the association between health anxiety and medical utilization. A secondary aim was to examine potential racial/ethnic differences in health anxiety. An ethnoracially diverse group of patients (N=533) seeking treatment from a primary care clinic completed a self-report measure of health anxiety. Three indices of medical utilization were assessed using medical records, including the number of: (a) clinic visits over the past two years, (b) current medications, and (c) lab tests over the past two years. Age moderated the effect of health anxiety on multiple indices of medical utilization. Supplemental analyses found that the moderating effect of age was specific to a somatic/body preoccupation, rather than health worry, dimension of health anxiety. Mean-level differences in health anxiety were either not supported (health anxiety composite, somatic/body preoccupation) or were small in magnitude (health worry) among self-identifying Black, Latino, and White participants. Results indicate that assessing for health anxiety could be particularly important for older adult patients who frequently seek out medical services.

Personality Disorders in Hypochondriasis: A Comparison to Panic Disorder and Healthy Controls

Previous studies found high prevalence rates of personality disorders (PDs) in patients with hypochondriasis; however, assessment was often based only on questionnaires. In the current study, a sample of 68 patients with hypochondriasis was compared to 31 patients with panic disorder and to 94 healthy controls. Participants were investigated with the Structured Clinical Interview for DSM-IV Personality Disorders questionnaire (SCID-II questionnaire) and the SCID-II interview. Based on the cut-off scores of the SCID-II questionnaire, we found a prevalence rate of 45.6% for PD in patients with hypochondriasis. In comparison to healthy controls, patients with hypochondriasis showed characteristics of paranoid, borderline, avoidant, and dependent PDs in the dimensional assessment significantly more often. However, no significant differences were found between the clinical samples. Based on the SCID-II interview, only 2.9% of the patients with hypochondriasis fulfilled the criteria for a PD. These results suggest that PDs are not a specific characteristic of hypochondriasis.

Changes in Free Symptom Attributions in Hypochondriasis after Cognitive Therapy and Exposure Therapy

BACKGROUND

Cognitive-behavioural therapy can change dysfunctional symptom attributions in patients with hypochondriasis. Past research has used forced-choice answer formats, such as questionnaires, to assess these misattributions; however, with this approach, idiosyncratic attributions cannot be assessed. Free associations are an important complement to existing approaches that assess symptom attributions.

AIMS

With this study, we contribute to the current literature by using an open-response instrument to investigate changes in freely associated attributions after exposure therapy (ET) and cognitive therapy (CT) compared with a wait list (WL).

METHOD

The current study is a re-examination of a formerly published randomized controlled trial (Weck, Neng, Richtberg, Jakob and Stangier, 2015) that investigated the effectiveness of CT and ET. Seventy-three patients with hypochondriasis were randomly assigned to CT, ET or a WL, and completed a 12-week treatment (or waiting period). Before and after the treatment or waiting period, patients completed an Attribution task in which they had to spontaneously attribute nine common bodily sensations to possible causes in an open-response format.

RESULTS

Compared with the WL, both CT and ET reduced the frequency of somatic attributions regarding severe diseases (CT: Hedges's g = 1.12; ET: Hedges's g = 1.03) and increased the frequency of normalizing attributions (CT: Hedges's g = 1.17; ET: Hedges's g = 1.24). Only CT changed the attributions regarding moderate diseases (Hedges's g = 0.69). Changes in somatic attributions regarding mild diseases and psychological attributions were not observed.

CONCLUSIONS

Both CT and ET are effective for treating freely associated misattributions in patients with hypochondriasis. This study supplements research that used a forced-choice assessment.

Changes in negative implicit evaluations in patients of hypochondriasis after treatment with cognitive therapy or exposure therapy

BACKGROUND AND OBJECTIVES

Previous studies using modified versions of the Affect Misattribution Procedure (AMP; Payne, Cheng, Govorun, & Stewart, 2005) have revealed that there is an implicit negative evaluation bias of illness-related information in patients with hypochondriasis (HYP), which might be a maintaining feature of HYP. However, there is no evidence on whether this bias might be targeted successfully by effective treatments, such as exposure therapy (ET) or cognitive therapy (CT). This is the first study to examine the change in negative implicit evaluations in a randomized controlled trial, including individual CT and ET, compared to a wait-list control group for HYP.

METHODS

An AMP with illness, symptom and neutral primes was used in 70 patients with HYP before and after treatment (wait-list respectively).

RESULTS

There was no significant change in negative implicit affective evaluations in both CT and ET, compared to wait-list. However, comparisons between the two active treatments revealed an interaction effect, that only for CT were the affective reactions on illness-as well as symptom-related prime trials (but not neutral primes) significantly more positive at post-compared to pre-treatment. In CT but not in ET, the reduction of implicit negative evaluation bias regarding symptom-related primes was significantly related to the reduction of self-reported health anxiety.

LIMITATIONS

The small subsample sizes for CT and ET, in comparison to wait-list, prohibit the detection of smaller effects.

CONCLUSIONS

Formal cognitive restructuring is necessary for reducing implicit negative evaluation bias in HYP, but the latter is not a prerequisite for reducing health anxiety. Thus, the importance of the negative implicit evaluation bias for the maintenance of HYP remains questionable.

Exposure therapy changes dysfunctional evaluations of somatic symptoms in patients with hypochondriasis (health anxiety). A randomized controlled trial

Dysfunctional evaluations of somatic symptoms are considered a central factor in maintaining hypochondriasis. The aim of the current study was to investigate whether exposure therapy (ET) without cognitive restructuring is sufficient to change dysfunctional evaluations of somatic symptoms. The current study was based on a randomized controlled trial and compared patients with hypochondriasis (N=73) receiving ET or cognitive therapy (CT) to a wait list (WL) control group. In both the ET and CT groups, dysfunctional symptom evaluations changed significantly compared with the WL group. No differences between the ET and CT groups emerged. The relationship between the treatment condition (active treatment vs. WL) and reductions in health anxiety was mediated by changes in somatic symptom evaluations only in a specific card sorting procedure. We conclude that addressing dysfunctional symptom evaluations is a necessary precondition for the effective treatment of hypochondriasis. However, the results indicate that ET and CT appear to change those processes to a similar degree.

Effectiveness of cognitive-behavioral group therapy for patients with hypochondriasis (health anxiety)

Cognitive behavioral therapy (CBT) has been shown to be highly effective in the treatment of health anxiety. However, little is known about the effectiveness of group CBT in the treatment of health anxiety. The current study is the largest study that has investigated the effectiveness of combined individual and group CBT for patients with the diagnosis of hypochondriasis (N=80). Therapy outcomes were evaluated by several questionnaires. Patients showed a large improvement on these primary outcome measures both post-treatment (Cohen's d=0.82-1.08) and at a 12-month follow-up (Cohen's d=1.09-1.41). Measures of general psychopathology and somatic symptoms showed significant improvements, with small to medium effect sizes. Patients with more elevated hypochondriacal characteristics at therapy intake showed a larger therapy improvement, accounting for 7-8% of the variance in therapy outcome. CBT group therapy has therefore been shown to be an appropriate and cost-effective treatment for health anxiety.

The role of disgust in patients with hypochondriasis

Theoretically, disgust sensitivity and disgust proneness could play an important role in hypochondriasis, since disgust is a defensive emotion widely believed to protect the organism from illness. However, empirical evidence to support this hypothesis has so far been based only on nonclinical samples, so that the importance and specificity of disgust for hypochondriasis remains unclear. In the current study, 36 patients with hypochondriasis, 27 with an anxiety disorder, and 29 healthy controls completed several measures which included the assessment of disgust sensitivity (Scale for the Assessment of Disgust Sensitivity) and disgust proneness (Questionnaire for the Assessment of Disgust Proneness). We found that patients with hypochondriasis and those with an anxiety disorder had higher scores than those of the healthy controls for several measures of disgust proneness. Moreover, measures of hypochondriacal characteristics were associated with those of disgust proneness and disgust sensitivity. However, no differences were found between patients with hypochondriasis and those with anxiety disorders, with respect to disgust proneness and disgust sensitivity. Therefore, it can be assumed that disgust proneness and disgust sensitivity seem to be less specific than previously suggested for the development and maintenance of hypochondriasis.