Enhanced Early Emotional Intrusion Effects and Proportional Habituation of Threat Response for Symptom and Illness Words in College Students with Elevated Health Anxiety

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.

The 14-item short health anxiety inventory (SHAI-14) used as a screening tool: appropriate interpretation and diagnostic accuracy of the Swedish version

BACKGROUND

The 14-item Short Health Anxiety Inventory (SHAI-14) is a common measure of health anxiety but its screening properties have not been studied. The aims of this study were to evaluate the SHAI-14 as a screening instrument, identify cut-offs for clinically significant health anxiety and investigate which scores correspond to different severity levels.

METHOD

The study included 1729 psychiatric patients and 85 healthy controls. Participants completed the SHAI-14 and underwent a diagnostic interview. Cut-off scores were evaluated in three scenarios to approximate screening 1) in a psychiatric clinic, 2) in a low prevalence setting and, 3) of healthy volunteers (cut-off for remission). Receiver operating characteristics were used. Classification of severity was based on the distribution of SHAI-14 scores reported by patients with clinically significant health anxiety.

RESULTS

The area under the curve (AUC) values were high in all scenarios (above 0.95). The optimal cut-off scores on the SHAI-14 were 22 in the psychiatric context, 29 in a setting with low prevalence of psychiatric disorders and 18 versus healthy controls. SHAI-14 scores of 0-27 represented no or mild health anxiety, 28-32 moderate health anxiety and 33-42 substantial health anxiety.

CONCLUSION

Brief self-report measures used as screening instruments are a simple way of gathering information about the presence of specific symptoms and thus a way to detect the likelihood of a diagnosis. The SHAI-14 shows evidence of good diagnostic utility in both clinical and non-clinical settings. However, which cut-off score is to be used, depends on the intended purpose and the setting where the cut-off is used.

Testing for the “Blues”: Using the Modified Emotional Stroop Task to Assess the Emotional Response of Gorillas

Simple Summary

We presented three adult male zoo-housed gorillas (Gorilla gorilla gorilla) with a modified emotional Stroop task on a computer touchscreen as a way to assess gorillas’ attentional shift for positively versus negatively valenced items. The gorillas learned to respond to a blue border and to withhold responding to a yellow border. Images of items assumed to have a positive or negative valence for the gorillas were placed within the borders. As predicted, gorillas touched the reinforced blue border more slowly when ‘negative’ images appeared within the blue border, compared to when ‘positive’ images appeared within the yellow border. However, gorillas’ accuracy did not vary as a function of which images appeared within the blue border, possibly because of the high levels of performance on all trials. These results validate the procedure to some degree for assessing the emotional valence of familiar stimuli.

Abstract

We adapted the emotional Stroop task developed for primates to test whether gorillas would show response slowing for images of ‘negative’ compared to images of ‘positive’ items placed within previously reinforced borders. Three zoo-housed male gorillas participated in six phases of an emotional Stroop paradigm. In Phase One, they learned to select blue borders over yellow borders in a forced choice task presented on the touchscreen. In Phase Two, neutral yellow or blue two-dimensional shapes were placed within the borders. On congruent trials, blue images were presented within both blue and yellow borders. On incongruent trials, yellow images were placed within both blue and yellow borders. We continued to use these trials as control trials in subsequent phases. We predicted that response latencies would be slower and accuracy would be lower on incongruent trials. Although the gorillas responded more quickly to incongruent trials, in contrast to predictions, they were more accurate on congruent trials, consistent with predictions. Therefore, we proceeded with Phase Three in which photographs of images assumed to have positive and negative valences for the gorillas were placed within the borders. On test trials, the same positive or negative image was placed within both borders. In Phase Four, a positive image was paired with a negative image on each trial and the positive image appeared in either the blue (congruent trials) or yellow border (incongruent trials). Phases Five and Six replicated Phases Three and Four with images of novel positive and negative items. The gorillas responded more quickly on congruent trials compared to incongruent trials on test trials but not on control trials throughout Phases 3–6. These findings provide some validation for the emotional Stroop task to test attentional shift with emotionally valenced items.

Attentional bias toward health-threat in health anxiety: a systematic review and three-level meta-analysis

Attentional bias toward health-threat may theoretically contribute to the development and maintenance of health anxiety, but the empirical findings have been controversial. This study aimed to synthesize and explore the heterogeneity in a health-threat related attentional bias of health-anxious individuals, and to determine the theoretical model that better represents the pattern of attentional bias in health anxiety. Four databases (Web of Science, PubMed, PsycINFO, and Scopus) were searched for relevant studies, with 17 articles (N = 1546) included for a qualitative review and 16 articles (18 studies) for a three-level meta-analysis (N = 1490). The meta-analytic results indicated that the health anxiety group, compared to the control group, showed significantly greater attentional bias toward health-threat (g = 0.256). Further analyses revealed that attentional bias type, paradigm, and stimuli type were significant moderators. Additionally, compared to the controls, health-anxious individuals displayed significantly greater attention maintenance (g = 0.327) but nonsignificant attention vigilance to health-threat (g = -0.116). Our results provide evidence for the attention maintenance model in health-anxious individuals. The implications for further research and treatment of elevated health anxiety in the context of coronavirus disease-2019 (COVID-19) were also discussed.

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.

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.

Cough Is Dangerous: Neural Correlates of Implicit Body Symptoms Associations

The negative interpretation of body sensations (e.g., as sign of a severe illness) is a crucial cognitive process in pathological health anxiety (HA). However, little is known about the nature and the degree of automaticity of this interpretation bias. We applied an implicit association test (IAT) in 20 subjects during functional magnetic resonance imaging (fMRI) to investigate behavioral and neural correlates of implicit attitudes toward symptom words. On the behavioral level, body symptom words elicited strong negative implicit association effects, as indexed by slowed reaction times, when symptom words were paired with the attribute “harmless” (incongruent condition). fMRI revealed increased activation in the dorsolateral prefrontal cortex (DLPFC) and posterior parietal cortex for the comparison of incongruent words with control words, as well as with a lower significance threshold also in comparison to congruent words. Moreover, activation in the DLPFC, posterior parietal cortex, nucleus accumbens, and cerebellum varied with individual levels of HA (again, in comparison to control words, as well as with a lower significance threshold also in comparison to congruent words). Slowed reaction times as well as increased activation in dorsolateral prefrontal and posterior parietal cortex point to increased inhibitory demands during the incongruent IAT condition. The positive association between HA severity and neural activity in nucleus accumbens, dorsolateral prefrontal, and posterior parietal cortex suggests that HA is characterized by both intensified negative implicit attitudes and hampered cognitive control mechanisms when confronted with body symptoms.

Implicit affective evaluation bias in hypochondriasis: findings from the Affect Misattribution Procedure

Cognitive theories of hypochondriasis (HYP) suggest that catastrophic misinterpretations of benign body sensations are a core feature for the maintenance of the disorder. There is tentative support from an analog sample that the interpretation of illness-related information also involves an implicit affective component. This is the first study to examine this negative affective evaluation bias implicitly in patients with HYP. An adapted version of the Affect Misattribution Procedure (AMP) with illness, symptom and neutral primes was used in 80 patients with HYP, and compared to 83 patients with an anxiety disorder (AD), as well as 90 healthy controls (CG). The HYP group showed significantly more negative affective reactions in illness prime trials, compared to both control groups, as well as more negative implicit evaluations on symptom prime trials, compared to the CG. Significant inverse relationships were observed only between the implicit evaluations of illness words and health anxiety questionnaires. Thus, an implicit negative affective evaluation bias of serious illnesses rather than symptoms is a unique feature of HYP.

Is the emotional Stroop task a special case of mood induction? Evidence from sustained effects of attention under emotion

Sustained effects of emotion are well known in everyday experience. Surprisingly, such effects are seldom recorded in laboratory studies of the emotional Stroop task, in which participants name the color of emotion and neutral words. Color performance is more sluggish with emotion words than with neutral words, the emotional Stroop effect (ESE). The ESE is not sensitive to the order in which the two groups of words are presented, so the effect of exposure to emotion words does not extend to disrupting performance in a subsequent block with neutral words. We attribute this absence of a sustained effect to habituation engendered by excessive repetition of the experimental stimuli. In a series of four experiments, we showed that sustained effects do occur when habituation is removed, and we also showed that the massive exposure to negative stimuli within the ESE paradigm induces a commensurately negative mood. A novel perspective is offered, in which the ESE is considered a special case of mood induction.

Health threat increases attentional bias for negative stimuli

BACKGROUND AND OBJECTIVES

Although there is some evidence that health anxiety is associated with attentional bias, relatively little research has examined the role of situational threat on bias. This study examined the effect of health threat on attentional bias for negative health words.

METHODS

Participants completed questionnaires and were then randomized to receive either threatening or reassuring health-related feedback. Following randomization, participants completed the emotional Stroop and dot-probe tasks in a counter-balanced order.

RESULTS

On the emotional Stroop task, all participants took longer to name the colour of negative words, as compared to positive and neutral words. However on the dot probe task, differences in attentional bias emerged based on feedback condition. Those receiving reassuring feedback displayed a bias away from negative words while those receiving threatening feedback did not display a bias either towards or away from negative words. Following reassuring feedback only, metacognitions were negatively correlated with attention towards positive health-related stimuli, suggesting another avenue for future research.

CONCLUSIONS

Health threats lead to an increase in the processing of negative information, and the effect of metacognitions on processing appears to be apparent only in the absence of health threat.

Neuronal and behavioral correlates of health anxiety: results of an illness-related emotional Stroop task

BACKGROUND

Health anxiety (HA) is defined as the objectively unfounded fear or conviction of suffering from a severe illness. Predominant attention allocation to illness-related information is regarded as a central process in the development and maintenance of HA, yet little is known about the neuronal correlates of this attentional bias.

METHODS

An emotional Stroop task with body symptom, illness, and neutral words was employed to elicit emotional interference in healthy participants with high (HA+, n = 12) and low (HA-, n = 12) HA during functional magnetic resonance imaging.

RESULTS

Prolonged reaction times for indicating the color of symptom words and a decrease in rostral anterior cingulate cortex (rACC) activation were seen in HA+ participants. Emotional interference effects on the behavioral level were negatively related to rACC activity over the whole group. Groups did not differ during the processing of threatening illness words.

CONCLUSION

The results indicate stronger attention allocation toward body symptom words already in subclinical HA. This attentional bias appears to be linked to hypoactivity of the rACC which impedes effective emotional interference reduction, leading instead to a ruminative processing of the stimulus content.

Attentional bias for trauma-related words: exaggerated emotional Stroop effect in Afghanistan and Iraq war veterans with PTSD

BACKGROUND

Post-traumatic stress disorder (PTSD) involves debilitating symptoms that can disrupt cognitive functioning. The emotional Stroop has been commonly used to examine the impact of PTSD on attentional control, but no published study has yet used it with Afghanistan and Iraq war veterans, and only one previous study has compared groups on habituation to trauma-related words.

METHODS

We administered the emotional Stroop, the Beck Depression Inventory (BDI), and the PTSD Checklist (PCL) to 30 veterans with PTSD, 30 military controls, and 30 civilian controls. Stroop word types included Combat, Matched-neutral, Neutral, Positive and Negative.

RESULTS

Compared to controls, veterans with PTSD were disproportionately slower in responding to Combat words. They were also slower and less accurate overall, did not show interference on Negative or Positive words relative to Neutral, and showed a trend for delayed but successful habituation to Combat words. Higher PCL and BDI scores also correlated with larger interference effects.

CONCLUSIONS

Because of its specificity in detecting attentional biases to trauma-related words, the emotional Stroop task may serve as a useful pre- and post task with intervention studies of PTSD patients.

Health anxiety and attentional bias: the time course of vigilance and avoidance in light of pictorial illness information

Cognitive-behavioral models of health anxiety stress the importance of selective attention not only towards internal but also towards external health threat related stimuli. Yet, little is known about the time course of this attentional bias. The current study investigates threat related attentional bias in participants with varying degrees of health anxiety. Attentional bias was assessed using a visual dot-probe task with health-threat and neutral pictures at two exposure durations, 175ms and 500ms. A baseline condition was added to the dot-probe task to dissociate indices of vigilance towards threat and difficulties to disengage from threat. Substantial positive correlations of health anxiety, anxiety sensitivity, and absorption with difficulties to disengage from threat were detected at 500ms exposure time. At an early stage (i.e., at 175ms exposure time), we found significant positive correlations of health anxiety and absorption with orientation towards threat. Results suggest a vigilance avoidance pattern of selective attention associated with pictorial illness related stimuli in health anxiety.

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.