The German Version of the H-YBOCS for the Assessment of Hypochondriacal Cognitions and Behaviors: Development, Reliability and Validity

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.

Krankheitsängste und Hypochondrische Störung

Fears of getting a severe disease (health anxiety) are widespread and their pathological manifestation as Hypochondriacal disorder (ICD-10) is cost-intensive for the health care system. In recent years advances in the research on and development of effective psychotherapeutic treatments have been made. Cognitive-behavioral therapy concepts currently are treatments of choice for Hypochondriacal disorder.

The assessment of cognitive-behavioral therapy skills in patients diagnosed with health anxiety: Development and pilot study on an observer-based rating scale

Cognitive-behavioral therapy is a highly effective treatment of health anxiety, but it remains unclear through which mechanisms treatment effects prevail. Some evidence suggests that patients acquire skills-understood as techniques helping them reach therapy goals-through psychotherapy. In the current study, an observer-based rating scale for the skills assessment of patients with health anxiety (SAPH) was developed and validated in a pilot study. Based on 177 videotapes, four independent raters evaluated the frequency of skills acquired during cognitive and exposure therapy among 66 patients diagnosed with health anxiety with the SAPH. Predictive validity was evaluated by the Yale-Brown Obsessive-Compulsive Scale for Hypochondriasis. The SAPH demonstrated good interrater reliability (ICC_(1,2)  = .88, p < .001, 95% CI [.81, .92]) and internal consistency (α = .94). Although patient skills did not significantly increase during three sessions, they significantly predicted a reduction in health anxiety symptoms at the end of treatment (R²  = .35). Patients' skills are highly important within the treatment of health anxiety. By providing external ratings of patients' skills with good psychometric properties, our pilot data suggest that the SAPH may complement current tools for the assessment of skills, specifically in targeting health anxiety.

Health anxiety symptoms in children and adolescents diagnosed with OCD

Health anxiety (HA) is an overlooked area in paediatric research. Little is known about the occurrence of HA symptoms in a child and adolescent psychiatric setting, and there are no age-appropriate diagnostic criteria and only limited number of assessment tools. It is therefore likely that HA is seen as part of obsessive-compulsive disorder (OCD) due to construct overlap and the diagnostic uncertainty of HA in this age group. In the present study, the extent of HA symptoms was investigated in 94 children and adolescents with a primary ICD-10 diagnosis of OCD. Self-reported HA symptoms were assessed using the Childhood Illness Attitude Scales. Clinician-rated OCD symptoms and severity were measured using the Children's Yale Brown Obsessive Compulsive Scale. Information on socio-demographics was obtained from the child's/adolescent's medical record. The distribution of HA symptoms resembled a normal curve shifted to the right compared with a normal population of Danish children, and 30 % presented with high HA symptoms. Chi-squared tests were used to examine the proportion of children and adolescents with high HA symptoms in relation to various clinical characteristics. Clinician-rated illness worries and comorbid anxiety disorder were associated with high self-reported HA symptoms. The results contribute to the understanding of how HA and OCD overlap conceptually in young patients and bring attention to the need for improved recognition of OCD patients dominated by illness worries. Further research in the description of childhood HA is important in order to understand whether HA is a distinct disorder early in life.

Patient Characteristics and Patient Behavior as Predictors of Outcome in Cognitive Therapy and Exposure Therapy for Hypochondriasis

OBJECTIVE

Psychotherapy for hypochondriasis has greatly improved over the last decades and cognitive-behavioral treatments are most promising. However, research on predictors of treatment outcome for hypochondriasis is rare. Possible predictors of treatment outcome in cognitive therapy (CT) and exposure therapy (ET) for hypochondriasis were investigated.

METHOD

Characteristics and behaviors of 75 patients were considered as possible predictors: sociodemographic variables (sex, age, and cohabitation); psychopathology (pretreatment hypochondriacal symptoms, comorbid mental disorders, and levels of depression, anxiety, and somatic symptoms); and patient in-session interpersonal behavior.

RESULTS

Severity of pretreatment hypochondriacal symptoms, comorbid mental disorders, and patient in-session interpersonal behavior were significant predictors in multiple hierarchical regression analyses. Interactions between the predictors and the treatment (CT or ET) were not found.

CONCLUSIONS

In-session interpersonal behavior is an important predictor of outcome. Furthermore, there are no specific contraindications to treating hypochondriasis with CT or ET.

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.

Response and Remission After Cognitive and Exposure Therapy for Hypochondriasis

Cognitive behavioral therapy has demonstrated large effect sizes for the treatment of hypochondriasis. However, response and remission rates, which provide important additional information about clinically significant improvements, have seldom been reported. In the current study, rates of response and remission after cognitive therapy and exposure therapy were evaluated. The study was based on a randomized controlled trial that treated patients with hypochondriasis (N = 75). The primary outcome measure was a clinician-administered structured interview for hypochondriasis. At posttreatment, response was found for 72.0% and remission for 45.3% of the patients. At 12-month follow-up, the response rate was 68.0%, and the remission rate was 54.7%. No significant differences in the frequency of response/remission were found between the cognitive therapy and the exposure therapy groups. Patients' and therapists' perspectives of clinical improvement corresponded with remission rather than response rates. Improvement rates were compared with those of other mental disorders, and implications for the treatment of hypochondriasis were discussed.

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.

Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis)

The role of treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) is rarely investigated in psychotherapeutic treatment for health anxiety. This study aimed to investigate the role of the assessment perspective for the evaluation of treatment delivery factors and their relevance for treatment outcome. Therapist adherence, therapist competence, and therapeutic alliance were evaluated by independent raters, therapists, patients, and supervisors in 68 treatments. Patients with severe health anxiety (hypochondriasis) were treated with cognitive therapy or exposure therapy. Treatment outcome was assessed with a standardized interview by independent diagnosticians. A multitrait-multimethod analysis revealed a large effect for the assessment perspective of therapist adherence, therapist competence, and therapeutic alliance. The rater perspective was the most important for the prediction of treatment outcome. Therapeutic alliance and therapist competence accounted for 6% of the variance of treatment outcome while therapist adherence was not associated with treatment outcome. Therapist competence was only indirectly associated with treatment outcome, mediated by therapeutic alliance. Both therapeutic alliance and therapist competence demonstrated to be important treatment delivery factors in psychotherapy for health anxiety. A stronger consideration of those processes during psychotherapy for health anxiety might be able to improve psychotherapy outcome.

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 Multidimensional Inventory of Hypochondriacal Traits

Severe health anxiety constitutes a disabling and costly clinical condition. The Multidimensional Inventory of Hypochondriacal Traits (MIHT) represents an innovative instrument that was developed according to cognitive-behavioral, cognitive-perceptual, interpersonal, and trait models of hypochondriasis. We aimed at evaluating the psychometric properties of the MIHT in a sample of patients with the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of hypochondriasis. Using confirmatory factor analysis (CFA), the postulated four-factor structure of the MIHT was found in a first CFA in patients with hypochondriasis ( n = 178) and in a second CFA based on a mixed sample, with other somatoform disorders ( n = 27), panic disorder ( n = 25), and healthy controls ( n = 31) added to the original group of patients with hypochondriasis ( n = 178). In terms of specificity, patients with hypochondriasis showed larger scores on all four MIHT subscales (i.e., affective, cognitive, behavioral, and perceptual) compared to all other groups. Analyses of convergent and discriminant validity revealed promising results concerning the MIHT affective and perceptual scales but also point to certain problematic issues concerning the MIHT cognitive and behavioral scales. The findings suggest that the proposed structure of the MIHT is valid also in patients with hypochondriasis and demonstrate the specificity of the four hypochondriacal traits assessed in the MIHT.

Assessing treatment integrity in cognitive-behavioral therapy: comparing session segments with entire sessions

The evaluation of treatment integrity (therapist adherence and competence) is a necessary condition to ensure the internal and external validity of psychotherapy research. However, the evaluation process is associated with high costs, because therapy sessions must be rated by experienced clinicians. It is debatable whether rating session segments is an adequate alternative to rating entire sessions. Four judges evaluated treatment integrity (i.e., therapist adherence and competence) in 84 randomly selected videotapes of cognitive-behavioral therapy for major depressive disorder, social anxiety disorder, and hypochondriasis (from three different treatment outcome studies). In each case, two judges provided ratings based on entire therapy sessions and two on session segments only (i.e., the middle third of the entire sessions). Interrater reliability of adherence and competence evaluations proved satisfactory for ratings based on segments and the level of reliability did not differ from ratings based on entire sessions. Ratings of treatment integrity that were based on entire sessions and session segments were strongly correlated (r=.62 for adherence and r=.73 for competence). The relationship between treatment integrity and outcome was comparable for ratings based on session segments and those based on entire sessions. However, significant relationships between therapist competence and therapy outcome were only found in the treatment of social anxiety disorder. Ratings based on segments proved to be adequate for the evaluation of treatment integrity. The findings demonstrate that session segments are an adequate and cost-effective alternative to entire sessions for the evaluation of therapist adherence and competence.