A taxometric study of hypochondriasis symptoms

Further Evidence for a Dimensional Latent Structure of Health Anxiety: Taxometric Analyses of the Whiteley Index Based on Two German Representative Samples

Health anxiety is an intricate part of illness anxiety and somatic symptom disorder. Based on convenience samples, two out of three available studies indicate that it is a dimensional rather than a categorical construct. Using two representative datasets, this study investigates whether previous results can be clarified. Conventional taxometric analyses as well as comparison curve fit indices (CCFI) profile analyses (MAMBAC and MAXSLOPE procedures) were calculated with two datasets of the German adult population assessing the Whiteley Index (WI-14, N = 2,072; WI-7, N = 2,498). Mean CCFIs indicated a dimensional structure for both the WI-7 (mean CCFI = 0.42, mean CCFI profile = 0.40) and the WI-14 (mean CCFI = 0.44, mean CCFI profile = 0.32). The results support and extend previous findings by strongly suggesting a dimensional distribution of health anxiety in the general population. Implications for research and practice comprise the adoption of a dimensional description of psychopathology as well as transdiagnostic treatment approaches.

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.

The relationship between interoceptive emotional awareness, neuroticism, and depression, anxiety, and stress

COVID-19 has caused challenges to daily living globally, with profound implications for negative mood. A variety of state and trait-based factors can influence how a person may respond and adapt to challenges such as a global pandemic. Personality is an area impacting how a person responds to both internal and external situations (trait) and Emotional Awareness (EA) is a facet of interoception (an awareness of the mind-body connection) that determines the way an individual interprets their physiological state of the body, and the associated emotions (state-trait). Both areas have been well researched in isolation, however the body of literature exploring the relationships between both is much smaller. It would therefore be beneficial to explore the interrelationships of both state and trait factors on wellbeing to enable a more comprehensive understanding. It was hypothesised that EA would moderate the relationship between Neuroticism and Depression, Anxiety, and Stress. Participants residing in Australia during periods of imposed lockdown were included within the study (n = 838; Ages = 18-60 years) and completed an online questionnaire battery including a variety of state and trait questionnaires. A moderation analysis was conducted to explore whether Emotional Awareness changed the relationship between neuroticism and depression, anxiety, and stress utilising an alpha of < .05. EA moderated the relationship between Neuroticism and Anxiety (p = .001, 95% CI .03-.17)), and Stress (p = .02 95% CI.01-.13), but not Depression (p = .23, 95% CI .03-.13). As Neuroticism increased, negative mood increased for all levels of EA, however those high in Neuroticism and EA displayed the highest Anxiety and Stress. Interventions to increase EA, such as mindfulness, may have adverse effects for individuals high in Neuroticism, emphasising the importance of tailored interventions and supporting the assumption that high levels of Neuroticism represent increased vulnerability during a pandemic.

Joint factor analysis and approximate equipercentile linking of common trait health anxiety measures: a cross-sectional study of the 14-, 18- and 64-item health anxiety inventory, the illness attitude scale, and the 14-item Whiteley Index

BACKGROUND

Research on health anxiety has bloomed in recent years, but summaries of the literature are complicated by the use of dissimilar self-report questionnaires. Furthermore, these instruments have rarely been administered in parallel, and especially not in clinical samples. In this study, we aimed to investigate the relationship between five widespread health anxiety measures, and to draft guidelines for the conversion of different sum scores.

METHODS

Clinical trial participants with principal pathological health anxiety (n = 335) and a sample of healthy volunteers (n = 88) completed the 14-item Whiteley Index (WI-14), the Illness Attitude Scale (IAS), and the 14-, 18-, and 64-item Health Anxiety Inventory (the HAI-64, HAI-18, and HAI-14). Cross-sectional data from all participants were pooled (N = 423) and we conducted a joint factor analysis and approximate equipercentile linking of the WI-14, IAS, HAI-64, HAI-18, and HAI-14.

RESULTS

Inter-scale correlations were high (rs ≥ 0.90 and ≥ 0.88 in adjusted analyses), and the scree plot of the joint factor analysis spoke for a unifactorial solution where 89/105 items (85%) had loadings ≥ 0.40. Most items at the core of this broad trait health anxiety factor pertained to the worry about health, the fear of having or developing a serious disease, and to some extent bodily preoccupation. We present a cross-walk table of observed equipercentile linked sum scores.

CONCLUSIONS

This study speaks clearly in favor of the WI-14, IAS, HAI-64, HAI-18, and HAI-14 all tapping into the same trait health anxiety construct, the core of which appears to concern the worry about health, the fear of having or developing a serious disease, and to some extent bodily preoccupation. Based on recently reported cut-offs for the HAI-14, a reasonable cutoff for pathological health anxiety in a psychiatric setting probably lies around 7-8 on the WI-14, 52-53 on the IAS, 82-83 on the HAI-64, and 26-27 on the HAI-18.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01966705, NCT02314065.

Validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder and illness anxiety disorder in pathological health anxiety: Should we close the chapter?

OBJECTIVE

To investigate the validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder (SSD) and illness anxiety disorder (IAD) in pathological health anxiety: the excessive and recurrent fear of, or preoccupation with, having or developing a serious health condition.

METHODS

We compared SSD to IAD in pathological health anxiety (N = 334) with regard to concurrent, antecedent, and predictive validators. This was primarily a cross-sectional study, though we studied the effect of CBT longitudinally. Because we were interested in the discriminatory value of SSD and IAD over and above trait health anxiety, we used trait health anxiety as a covariate.

RESULTS

SSD (68%; 228/334) vs. IAD (32%; 106/334) differences were mostly non-significant and small in sociodemographics, core clinical characteristics, apparent course, etiological attribution, and physician visits (gs = -0.18-0.20; RRs = 0.84-1.09; IRRs = 0.87-0.99). However, SSD was associated with a significantly higher somatic symptom burden (gs = 0.20-0.72), more psychologist visits (IRR = 2.02, 95% CI: 1.24-3.28), and slightly higher disability (g = 0.22, 95% CI: 0.03-0.42). There was no significant difference in symptom reduction during CBT (g = -0.16, 95% CI: -0.37-0.05).

CONCLUSION

Although not all differences between SSD and IAD in pathological health anxiety seem to be explained by the level of trait health anxiety, the SSD vs. IAD distinction appears to convey little useful information in pathological health anxiety. Tentatively, considering the well-documented clinical characteristics and effective clinical interventions, it is probably most helpful to regard pathological health anxiety as a de facto anxiety or perhaps obsessive-compulsive spectrum disorder, regardless of the DSM-5 diagnosis of SSD or IAD.

Health Anxiety by Proxy Disorder: A Case Report

Health anxiety by proxy (HAP) is a newly introduced term in psychiatry to describe the anxious feelings or fear of having or acquiring a serious illness. It is often accompanied by maladaptive illness behavior in the absence of true somatic symptoms. This, in turn, entails seeking medical advice and therefore doing many unnecessary investigations in an attempt to justify these symptoms. Functional impairment may appear in HAP patients, and this indicates a pathological point. To some extent, it can be said that HAP is similar to health anxiety disorder in terms of symptomatology and items. However, it is imposed on another (usually the patients' children) instead of the patient himself. Many biopsychosocial factors are suggested to play a role in the psychopathology of HAP. Until now, there are no well-established criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) or International Classification of Diseases 11^th Revision (ICD-11) to make the diagnosis of health anxiety by proxy. Although treatment protocols are missing, it appears that patients are not responding to treatment protocols for illness anxiety disorder. This requires focusing attention on conducting studies on those patients to develop clear treatment plans to help patients. In this report, we present a 28-year-old female with constant worries about her child's health, which subsequently resulted in seeking medical advice at multiple clinics with different medical specialties. Many factors were thought to be implicated in triggering her current condition. The anxious feelings reflected negatively on the patient's life, resulting in a poor functioning status. A treatment plan was initiated with a dismal response and fluctuating course. Additionally, we discussed the initial definition and the bases that could be used to facilitate the diagnosis and management of HAP disorder.

Conceptualizations of Cyberchondria and Relations to the Anxiety Spectrum: Systematic Review and Meta-analysis

BACKGROUND

Cyberchondria describes the detrimental effects of health-related internet use. Current conceptualizations agree that cyberchondria is associated with anxiety-related pathologies and may best be conceptualized as a safety behavior; however, little is known about its exact underlying mechanisms.

OBJECTIVE

This systematic review and meta-analysis aims to give an overview of the conceptualizations of cyberchondria and its relation to anxiety-related pathologies, quantify the strength of association to health anxiety by using meta-analyses, highlight gaps in the literature, and outline a hypothetical integrative cognitive-behavioral model of cyberchondria based on the available empirical evidence.

METHODS

A systematic literature search was conducted using PubMed, Web of Science, and PsycINFO electronic databases. A total of 25 studies were included for qualitative synthesis and 7 studies, comprising 3069 individuals, were included for quantitative synthesis. The meta-analysis revealed a strong association of cyberchondria (r=0.63) and its subfacets (r=0.24-0.66) with health anxiety.

RESULTS

The results indicate that cyberchondria is a distinct construct related to health anxiety, obsessive-compulsive symptoms, intolerance of uncertainty, and anxiety sensitivity. Further studies should distinguish between state and trait markers of anxiety-related pathologies and use experimental and naturalistic longitudinal designs to differentiate among risk factors, triggers, and consequences related to cyberchondria.

CONCLUSIONS

Health-related internet use in the context of health anxiety is best conceptualized as health-related safety behavior maintained through intermittent reinforcement. Here, we present a corresponding integrative cognitive-behavioral model.

Psychometric Evaluation of the Whiteley Index-8 in Chinese Outpatients in General Hospitals

Background: Excessive and persistent health anxiety is a common and disabling but often unrecognized illness. Therefore, screening patients for health anxiety is recommended in primary care. The aim of the present study was to examine the psychometric properties of an updated version of the eight-item Whiteley Index (WI-8) among outpatients in general hospitals in China. Methods: The presented data were derived from a multicenter cross-sectional study. The Chinese version of the WI-8 was administered to a total of 696 outpatients. Cronbach's alpha was used to evaluate the internal consistency of the scale. The validity of the scale was evaluated based on factor analysis and correlation analyses. To assess the discriminant ability, receiver operating characteristic (ROC) analysis was conducted. Results: Cronbach's alpha was 0.937, and it decreased (0.925) after deleting the new 8th item. Factor analysis extracted one factor accounting for 69.2% of the variance. Moderate correlations were found (0.414-0.662) between the WI-8 and General Anxiety Disorder (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder B-criteria (SSD-12). The ROC curve indicated excellent discriminatory ability to discriminate among patients with health anxiety (AUC = 0.822). Conclusions: The new WI-8 version is a reliable and valid tool to screen for health anxiety in general hospital patients. We recommend the WI-8 as a useful screening tool for health anxiety.

Relationships between radiation risk perception and health anxiety, and contribution of mindfulness to alleviating psychological distress after the Fukushima accident: Cross-sectional study using a path model

One of biggest public health impacts of the Fukushima Daiichi Nuclear Power Station accident is psychosocial. Anxiety about radiation is still present, and radiation risk perception, particularly with regard to genetic effects, is known to affect mental health. However, roles of other risk factors such as health anxiety and of mindfulness remain to be proved. Here, we examined how radiation risk perception (genetic effects) mediates in health anxiety and psychological distress, and how mindfulness influences those variables. Seven years after the accident, we commissioned a self-reported online survey with 832 participants, 416 each from Fukushima and Tokyo, and modeled the relationship between those variables using Structural Equation Modeling. Health anxiety had a much stronger influence on psychological distress than radiation risk perception. Mindfulness was significantly correlated with both health anxiety and psychological distress, but not with radiation risk perception. The total effects on psychological distress were -0.38 by mindfulness and +0.38 by health anxiety. These results suggest the potential application of mindfulness-based interventions to alleviate health anxiety and psychological distress rather than therapy focused on radiation anxiety. The results underline the effectiveness of community support efforts in Fukushima and highlight the importance of enhancing mindfulness during the chronic phase following a disaster.

Dimensions over categories: a meta-analysis of taxometric research

Taxometric procedures have been used extensively to investigate whether individual differences in personality and psychopathology are latently dimensional or categorical ('taxonic'). We report the first meta-analysis of taxometric research, examining 317 findings drawn from 183 articles that employed an index of the comparative fit of observed data to dimensional and taxonic data simulations. Findings supporting dimensional models outnumbered those supporting taxonic models five to one. There were systematic differences among 17 construct domains in support for the two models, but psychopathology was no more likely to generate taxonic findings than normal variation (i.e. individual differences in personality, response styles, gender, and sexuality). No content domain showed aggregate support for the taxonic model. Six variables - alcohol use disorder, intermittent explosive disorder, problem gambling, autism, suicide risk, and pedophilia - emerged as the most plausible taxon candidates based on a preponderance of independently replicated findings. We also compared the 317 meta-analyzed findings to 185 additional taxometric findings from 96 articles that did not employ the comparative fit index. Studies that used the index were 4.88 times more likely to generate dimensional findings than those that did not after controlling for construct domain, implying that many taxonic findings obtained before the popularization of simulation-based techniques are spurious. The meta-analytic findings support the conclusion that the great majority of psychological differences between people are latently continuous, and that psychopathology is no exception.

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

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

Moving toward a metacognitive conceptualization of cyberchondria: Examining the contribution of metacognitive beliefs, beliefs about rituals, and stop signals

Cyberchondria refers to the repeated use of the Internet to search for health information that leads to negative consequences. The present set of studies examined the tenability of a proposed metacognitive conceptualization of cyberchondria that includes metacognitive beliefs about health-related thoughts, beliefs about rituals, and stop signals. The contribution of those variables to cyberchondria was examined among 330 undergraduate students from a U.S. university in Study 1 and 331 U.S. community respondents in Study 2. All participants reported using the Internet to search for health information. Across both studies, metacognitive beliefs, beliefs about rituals, and stop signals shared positive bivariate associations with cyberchondria and accounted for unique variance in cyberchondria scores in multivariate analyses. Beliefs about rituals and stop signals emerged as relatively specific to cyberchondria versus health anxiety in multivariate analyses. Results provide preliminary support for a metacognitive conceptualization of cyberchondria, with extensions of the present findings discussed.

Cost-effectiveness and long-term follow-up of three forms of minimal-contact cognitive behaviour therapy for severe health anxiety: Results from a randomised controlled trial

Strategies to increase the availability of cognitive behaviour therapy (CBT) for severe health anxiety (SHA) are needed, and this study investigated the cost-effectiveness and long-term efficacy of three forms of minimal-contact CBT for SHA. We hypothesised that therapist-guided internet CBT (G-ICBT), unguided internet CBT (U-ICBT), and cognitive behavioural bibliotherapy (BIB-CBT) would all be more cost-effective than a waiting-list condition (WLC), as assessed over the main phase of the trial. We also hypothesised that improvements would remain stable up to one-year follow-up. Adults (N = 132) with principal SHA were randomised to 12 weeks of G-ICBT, U-ICBT, BIB-CBT, or WLC. The primary measure of cost-effectiveness was the incremental cost-effectiveness ratio, or the between-group difference in per capita costs divided by the between-group difference in proportion of participants in remission. The Health anxiety inventory (HAI) was the primary efficacy outcome. G-ICBT, U-ICBT, and BIB-CBT were more cost-effective than the WLC. Over the follow-up period, the G-ICBT and BIB-CBT groups made further improvements in health anxiety, whereas the U-ICBT group did not change. As expected, all three treatments were cost-effective with persistent long-term effects. CBT without therapist support appears to be a valuable alternative to G-ICBT for scaling up treatment for SHA.

Metacognitive beliefs as a predictor of health anxiety in a self-reporting Italian clinical sample

Research has supported the specific role that anxiety sensitivity, health-related dysfunctional beliefs, and metacognitive beliefs may play in the development and maintenance of health anxiety symptoms. However, the role of metacognitive beliefs in health anxiety has only been explored in analogue samples. The aim of this study was to explore for the first time the association between metacognitive beliefs and health anxiety symptoms in a sample of participants who reported having received a diagnosis of severe health anxiety (hypochondriasis) or illness anxiety disorder and test whether these beliefs are significant predictors of health anxiety after controlling for anxiety, depression, anxiety sensitivity, and dysfunctional beliefs. A series of dimensional self-report measures were administered to a large Italian sample (N = 458). At a bivariate level, Beliefs that Thoughts are Uncontrollable had a stronger association with health anxiety than any of the dysfunctional beliefs and anxiety sensitivity subscales. Results from hierarchical multiple regression analysis indicated that Beliefs that Thoughts are Uncontrollable predicted health anxiety symptoms over-and-above depression, general anxiety, anxiety sensitivity, and health-related dysfunctional beliefs. Despite many important limitations, this study supported the hypothesis that metacognition may have an important role in health anxiety in clinical samples.

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.

Multidimensional Inventory of Hypochondriacal Traits: An Examination of a Bifactor Model and Measurement Invariance Between Those With and Without a Self-Reported Medical Condition

The Multidimensional Inventory of Hypochondriacal Traits (MIHT) is a self-report measure that assesses four interrelated domains of health anxiety (i.e., Cognitive, Behavioral, Perceptual, Affective). Prior research has supported a correlated four-factor model, as well as a hierarchical model, in which each of the four factors load onto the higher order health anxiety construct. However, a bifactor modeling approach has yet to be used to examine the factor structure of the MIHT. Results supported a bifactor model of the MIHT in three different samples (i.e., unselected based on current medical status [n = 824], and those with [n = 348] and without [n = 354] a self-reported medical condition). The MIHT appears to be strongly multidimensional, with three of the four subscales providing substantive value. Confirmatory factor analysis supported the configural and metric/scalar invariance of the bifactor model between those with and without a self-reported medical condition. Results provide support for a bifactor conceptualization of the MIHT and the invariance of that model across levels of current health status.

The Role of Emotion Reactivity in Health Anxiety

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

Cyberchondria: Examining relations with problematic Internet use and metacognitive beliefs

Cyberchondria refers to the repeated use of the Internet to search for health-related information, which leads to negative consequences. This two-part study provides the first known examination of how cyberchondria relates to (a) problematic Internet use and (b) metacognitive beliefs. Participants were U.S. community adults who reported using the Internet to search for health-related information (Study 1: N = 337, Study 2: N = 260). In Study 1, cyberchondria shared a strong association with problematic Internet use, and that association was unaccounted for by age, gender, current reported medical status, negative affect, or health anxiety. In Study 2, cyberchondria was found to share moderate to strong associations with metacognitive beliefs. The association between cyberchondria and metacognitive beliefs about the uncontrollability of thoughts remained intact after accounting for the Study 1 covariates, as well as anxiety sensitivity and intolerance of uncertainty. Neither anxiety sensitivity nor intolerance of uncertainty shared unique associations with cyberchondria. These results provide a preliminary indication that a metacognitive conceptualization of problematic Internet use may be applicable to cyberchondria.

From headache to tumour: An examination of health anxiety, health-related Internet use and ‘query escalation’

The current study aimed to explore the phenomenon of disease-related ‘query escalation’ in high/low health anxious Internet users ( N = 40). During a 15-minute health-related Internet search, participants rated their anxiety and the perceived seriousness of information on each page. Post-search interviews determined the reasons for, and effects of, escalating queries to consider serious diseases. Both groups were found to be significantly more anxious after escalating queries. The high group was significantly more likely to escalate queries. Evaluating personal relevance of material was the main reason for escalations and moderated anxiety post-escalation. We conclude that searching for online disease information can increase anxiety, particularly for people worried about their health.

The combination of health anxiety and somatic symptoms: Specificity to anxiety sensitivity cognitive concerns among patients in primary care

Prior research has found that health anxiety is related to poor patient outcomes in primary care settings. Health anxiety is characterized by at least two presentations: with either severe or no/mild somatic symptoms. Preliminary data indicate that anxiety sensitivity may be important for understanding the presentation of health anxiety with severe somatic symptoms. We further examined whether the combination of health anxiety and somatic symptoms was related to anxiety sensitivity. Participants were adults presenting for treatment at a community health center (N=538). As predicted, the interactive effect between health anxiety and somatic symptoms was associated with anxiety sensitivity cognitive concerns. Health anxiety shared a stronger association with anxiety sensitivity cognitive concerns when coupled with severe, relative to mild, somatic symptoms. Contrary to predictions, the interactive effect was not associated with the other dimensions of anxiety sensitivity. We discuss the potential relevancy of anxiety sensitivity cognitive concerns to the combined presentation of health anxiety and severe somatic symptoms, as well as how this dimension of anxiety sensitivity could be treated in primary care settings.

The Whiteley Index-6: An Examination of Measurement Invariance Among Self-Identifying Black, Latino, and White Respondents in Primary Care

Brief measures that are comparable across disparate groups are particularly likely to be useful in primary care settings. Prior research has supported a six-item short form of the Whiteley Index (WI), a commonly used measure of health anxiety, among English-speaking respondents. This study examined the measurement invariance of the WI-6 among Black ( n = 183), Latino ( n = 173), and White ( n = 177) respondents seeking treatment at a U.S. community health center. Results supported a bifactor model of the WI-6 among the composite sample ( N = 533), suggesting the presence of a general factor and two domain-specific factors. Results supported the incremental validity of one of the domain-specific factors in accounting for unique variance in somatic symptom severity scores beyond the general factor. Multiple-groups confirmatory factor analysis supported the configural, metric, ands scalar invariance of the bifactor WI-6 model across the three groups of respondents. Results provide support for the measurement invariance of the WI-6 among Black, Latino, and White respondents. The potential use of the WI-6 in primary care, and broader, settings is discussed.

Does cyberchondria overlap with health anxiety and obsessive-compulsive symptoms? An examination of latent structure and scale interrelations

Searching for medical information online is a widespread activity that increases distress for many individuals. Researchers have speculated that this phenomenon, referred to as cyberchondria, overlaps substantially with both health anxiety and obsessive-compulsive symptoms. This study sought to examine: (1) the distinguishability of cyberchondria from health anxiety and obsessive-compulsive symptoms and (2) the components of health anxiety and obsessive-compulsive symptoms that cluster most strongly with cyberchondria. The sample consisted of community adults in the United States with no current reported medical problems (N=375). Results from confirmatory factor analyses (CFAs) support the idea that cyberchondria is distinct from, yet related to, health anxiety and obsessive-compulsive symptoms. Results from zero-order correlations and regression analyses suggest that cyberchondria clusters with the affective (health worry) component of health anxiety. Regression results diverged from prior findings, as obsessive-compulsive symptoms did not share associations with cyberchondria after accounting for negative affect and health anxiety. The present results indicate that cyberchondria is possibly discernible from both health anxiety and obsessive-compulsive symptoms, while also providing insight into areas of potential overlap.

Is metacognition a causal moderator of the relationship between catastrophic misinterpretation and health anxiety? A prospective study

Psychological theories have identified a range of variables contributing to health anxiety, including, dysfunctional illness beliefs, catastrophic misinterpretation, somatosensory amplification and neuroticism. More recently, metacognitive beliefs have been proposed as important in health anxiety. This study aimed to test the potential causal role of metacognitive beliefs in health anxiety. A prospective design was employed and participants (n = 105) completed a battery of questionnaire at two time points (6 months apart). Results demonstrated that cognitive, personality and metacognitive variables were bi-variate prospective correlates of health anxiety. Hierarchical regression analysis revealed that only metacognitive beliefs emerged as independent and significant prospective predictors of health anxiety. Moderation analysis demonstrated that metacognitive beliefs prospectively moderated the relationship between catastrophic misinterpretation and health anxiety. Follow-up regression analysis incorporating the interaction term (metacognition × misinterpretation) showed that the term explained additional variance in health anxiety. The results confirm that metacognition is a predictor of health anxiety and it is more substantive than misinterpretations of symptoms, somatosensory amplification, neuroticism, and illness beliefs. These results may have major implications for current cognitive models and for the treatment of health anxiety.

Anxiety sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria: A replication and extension examining dimensions of each construct

BACKGROUND

Preliminary findings suggest that anxiety sensitivity (AS) and intolerance of uncertainty (IU) may confer vulnerability for cyberchondria, defined as repeated internet searches for medical information that exacerbates health anxiety. Prior studies are limited because it remains unclear whether specific AS or IU dimensions differentially relate to certain cyberchondria dimensions.

METHODS

The present study examined associations among AS, IU, and cyberchondria dimensions using a sample of community adults (N = 578) located in the United States.

RESULTS

As predicted, physical AS and inhibitory IU were the only AS or IU dimensions to share unique associations with the distress cyberchondria dimension after controlling for the overlap among the AS dimensions, IU dimensions, and health anxiety. Cognitive AS and social AS unexpectedly evidenced unique associations with cyberchondria dimensions.

LIMITATIONS

The results are limited by the cross-sectional study design and use of a community, rather than clinical, sample.

CONCLUSIONS

This study provides evidence that specific AS and IU dimensions may confer vulnerability to certain cyberchondria dimensions. Further clarifying associations among AS, IU, and cyberchondria may lead to improvements in our conceptualization and, ultimately, treatment of cyberchondria.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

Metacognitive beliefs moderate the relationship between catastrophic misinterpretation and health anxiety

Catastrophic misinterpretations of bodily symptoms have a central role in cognitive-behavioural models of health anxiety. However, the metacognitive (S-REF) model postulates that psychological disturbance is linked more to beliefs about thinking i.e., metacognition. Equally the relationship between catastrophic misinterpretation and health anxiety should be moderated by metacognition, in particular negative beliefs about the uncontrollability and danger of thinking (MCQNeg). Participants (N = 351) completed measures to examine the relationship between these variables. Results indicated positive relationships between metacognition, catastrophic misinterpretation, and health anxiety. Moderation analysis showed that the effect of catastrophic misinterpretations on health anxiety was explained by the proposed interaction with metacognition. Follow-up regression analysis demonstrated the interaction term explained variance in health anxiety when controlling for other variables, and was a stronger unique predictor of health anxiety than catastrophic misinterpretation. Metacognition appears to be an important factor in the relationship between catastrophic misinterpretation and health anxiety, and would have important implications for existing models and treatment.

Mismanagement of a hypochondriacal patient

Hypochondriasis is a persistent preoccupation that despite appropriate medical evaluations and assurance of patient's physical health, the patient insists on having a serious disease. The case which is discussed in this article is a 39-years-old woman that hospitalized for half of her life and no one can perceive her disorder according to her assertions. The mentioned case is a "difficult patient" with fear of oxygen shortage and being choked (Pnigophobia) which leads to continuous tendency to wear oxygen device even during sleep. There is no benefit in exaggerating her condition for herself so there is no fictitious disorder considered. During the therapy she has been assured that she does not have a serious disease and she has learnt to decrease oxygen intake and breath with his mouth. The point that makes this study different from the others is that most of hypochondriacal patients have a fear of getting HIV, cancers, hepatitis and MS but our patient has phobia of pulmonary embolism.

Examining the Specific Facets of Distress Tolerance That Are Relevant to Health Anxiety

Researchers have called for examinations of associations between distinct facets of distress tolerance and specific forms of psychopathology. We examined associations between five facets of distress tolerance (intolerance of uncertainty, ambiguity, frustration, negative emotion, and physical discomfort) and health anxiety using a large community sample of adults. Structural equation modeling was used to examine associations. Intolerance of uncertainty, negative emotion, and physical discomfort were the only facets of distress tolerance that shared unique associations with health anxiety after accounting for the overlap among the facets of distress tolerance. Intolerance of physical discomfort shared an especially strong unique association with health anxiety. These results highlight facets of distress tolerance that are particularly relevant to health anxiety. Conceptual and therapeutic implications are discussed.

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.

The Cyberchondria Severity Scale (CSS): an examination of structure and relations with health anxiety in a community sample

McElroy and Shevlin (2014) developed the 33-item Cyberchondria Severity Scale (CSS) to allow for a multidimensional assessment of cyberchondria (compulsion, distress, excessiveness, reassurance, and mistrust of medical professional). The present study evaluated psychometric properties of the CSS, including its factor structure, internal consistency, convergent validity, and incremental validity, using a large sample of community adults located in the United States (N=539). Results from a confirmatory factor analysis (CFA) supported the adequacy of the five-factor structure of the CSS. However, results from a higher-order CFA indicated that the mistrust of medical professional factor does not assess the same construct as the other factors of the CSS. The CSS scales evidenced adequate internal consistency and significantly correlated with health anxiety. The distress, excessiveness, and mistrust of medical professional scales correlated significantly more strongly with health anxiety than obsessive-compulsive symptoms and these three scales were the only CSS scales to share unique variance with health anxiety. Implications of these results for future research are discussed.

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.

Linking Illness in Parents to Health Anxiety in Offspring: Do Beliefs about Health Play a Role?

BACKGROUND

The cognitive behavioural (CB) model of health anxiety proposes parental illness leads to elevated health anxiety in offspring by promoting the acquisition of specific health beliefs (e.g. overestimation of the likelihood of illness).

AIMS

Our study tested this central tenet of the CB model.

METHOD

Participants were 444 emerging adults (18-25-years-old) who completed online measures and were categorized into those with healthy parents (n = 328) or seriously ill parents (n = 116).

RESULTS

Small (d = .21), but significant, elevations in health anxiety, and small to medium (d = .40) elevations in beliefs about the likelihood of illness were found among those with ill vs. healthy parents. Mediation analyses indicated the relationship between parental illness and health anxiety was mediated by beliefs regarding the likelihood of future illness.

CONCLUSIONS

Our study incrementally advances knowledge by testing and supporting a central proposition of the CB model. The findings add further specificity to the CB model by highlighting the importance of a specific health belief as a central contributor to health anxiety among offspring with a history of serious parental illness.

Health anxiety, cognitive coping, and emotion regulation: a latent variable approach

BACKGROUND

Health anxiety, the fear or conviction of suffering from a severe disorder, represents a dimensional and multifactorial construct consisting of cognitive, behavioral, affective, and perceptual components. It has recently been proposed that dysfunctional emotion regulation strategies contribute to health anxiety, but the empirical evidence for this claim is sparse.

PURPOSE

The current research was aimed at broadly exploring and clarifying possible relationships between dimensions of health anxiety and cognitive coping and emotion regulation strategies.

METHOD

In two studies with non-clinical samples (n study 1 = 172; n study 2 = 242), health anxiety, cognitive coping, and emotion regulation strategies were assessed using multidimensional self-report measures. Functional (e.g., reappraisal) and dysfunctional (e.g., rumination) cognitive coping and emotion regulation strategies were differentiated.

RESULTS

Using structural equation modeling, the results of Study 1 revealed significant and consistent associations between the dimensions of health anxiety and dysfunctional coping and emotion regulation strategies. Study 2 replicated and extended the main findings of Study 1 by demonstrating that the associations between health anxiety and strategies of coping and emotion regulation were independent of the current level of depressive symptoms.

CONCLUSION

Health anxiety was found to be associated with dysfunctional coping and emotion regulation strategies (e.g., suppression). The positive associations between behavioral dimensions of health anxiety (e.g., seeking reassurance) and dysfunctional coping strategies may suggest that behavioral dimensions of health anxiety serve as a compensatory strategy to overcome difficulties in cognitive coping.

Health anxiety--an indicator of higher interoceptive sensitivity?

BACKGROUND AND OBJECTIVES

According to cognitive-behavioral models, health anxiety arises from the misattribution of normal bodily sensations as signs of a severe illness. Consequently, higher levels of interoceptive accuracy might be critically involved in the development of health anxiety.

METHODS

To test this central assumption of cognitive behavioral models of health anxiety, we assessed interoceptive accuracy in a sample of college students (N = 100). Two interoceptive tasks (detection of one's own heartbeat using the Schandry paradigm and detection of nonspecific skin conductance fluctuations, NSCFs) were used.

RESULTS

We found no indication for a positive association between facets of health anxiety and a higher interoceptive accuracy in the two tasks. In fact, worse heartbeat perception was associated with higher health anxiety as measured by two questionnaires whereas perception of NSCFs was not significantly related to any facet of health anxiety. In addition, we found a bias to overestimate NSCFs in people with heightened health anxiety.

LIMITATIONS

Because a sample of college students served as participants, the generalization of the findings is limited and further studies in patients with the diagnosis of hypochondriasis are necessary.

CONCLUSIONS

The findings of both interoceptive paradigms suggest that health anxiety is not associated with better but rather with less accurate and biased interoceptive sensitivity. Probably, not a heightened interoceptive sensitivity but rather the bias in overestimating harmless somatic cues is more relevant for the maintenance of health anxiety. Our results are in line with recent research in other somatoform disorders.

An examination of the incremental contribution of emotion regulation difficulties to health anxiety beyond specific emotion regulation strategies

Given the potential transdiagnostic importance of emotion dysregulation, as well as a lack of research examining emotion dysregulation in relation to health anxiety, the present study sought to examine associations among specific emotion regulation strategies (cognitive reappraisal and expressive suppression), emotion regulation difficulties, and health anxiety in a physically healthy sample of adults (N=482). As hypothesized, results of a series of hierarchical multiple regression analyses showed that emotion regulation difficulties provided a significant incremental contribution, beyond the specific emotion regulation strategies, in predicting each of the three health anxiety variables. Among the six dimensions of emotion regulation difficulties, the dimension representing perceived access to effective emotion regulation strategies was the only emotion regulation difficulty dimension that predicted all three health anxiety variables beyond the effects of the specific emotion regulation strategies. Results indicate that emotion regulation difficulties, and particularly one's subjective appraisal of his/her ability to effectively regulate emotions, may be of importance to health anxiety. Clinical implications are discussed.

The Combination of Health Anxiety and Somatic Symptoms: Examining Associations With Health-Related Beliefs and Gender Differences

Current diagnostic criteria suggest that some individuals experience health anxiety and severe somatic symptoms, whereas others experience health anxiety and either no or mild somatic symptoms. However, to date, our understanding of potential differences among individuals with health anxiety and varying severity of somatic symptoms remains limited. Adopting a dimensional approach, we completed this study to help fill this gap in the literature by examining whether the interactive effect between health anxiety and somatic symptoms was related to health-related beliefs among men (n = 211) and women (n = 220). Among both men and women, health anxiety was related to certain health-related beliefs, particularly anxiety sensitivity, only when coupled with severe somatic symptoms. Conceptual and therapeutic implications of these results are discussed.

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.

Health anxiety disorders in older adults: conceptualizing complex conditions in late life

Health anxiety disorders (e.g., hypochondriasis) are prevalent but understudied in older adults. Existing research suggests that severe health anxiety has a late age of onset, perhaps because of comorbidity with physical health conditions that are more likely to occur with aging. Despite being under diagnosed in later life due to a lack of age-appropriate diagnostic criteria, significant positive associations with age suggest that health anxiety disorders are more prevalent in older than younger adults. Preliminary research also highlights the complexity of these disorders in older adults and the potential importance of medical morbidity as a risk factor. This review explores the complexities of health anxiety disorders in later life with a focus on understanding defining features, prevalence rates, correlates, assessment, diagnosis, and treatment. We offer a theoretical model of the development of severe health anxiety among older adults to encourage further research on this important and under-studied topic.

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.