Hypochondriasis: the role of fear-confirming reasoning

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

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

An Observational Study of OCD Patients Treated With Cognitive Behavioral Therapy During the COVID-19 Pandemic

Background and Objectives: While the consequences of the COVID-19 pandemic for general mental health and the increase in anxiety and depression are clear, less is known about the potential effect of the pandemic on OCD. The purpose of this study is to collect new data to monitor the symptomatic status of patients with OCD during the period of emergency due to COVID-19 and to make a comparison between two psychodiagnostic evaluations. Methods: Eleven OCD patients and their psychotherapists were recruited. All patients had a specific psychodiagnostic assessment for OCD (SCL-90; OCI-R; Y-BOCS self-report) performed between December 2019 and January 2020 (t0), and undertook cognitive behavioral therapy (CBT) and exposure and prevention of response protocol (ERP) before the lockdown. The psychodiagnostic assessment carried out at t0 was re-administered (t1) to all patients, together with a set of qualitative questions collected through an online survey. The respective therapists were asked to document the status of the therapy and the monitoring of symptoms through use of a semi-structured interview (Y-BOCS) and a qualitative interview. Non-parametric analyses were conducted. Results: Patients reported a significant decrease in OCD symptoms. Data analysis showed a decrease in the scores across t0 and at t1 on the Y-BOCS (SR) total self-report, and on OCD symptoms' severity assessed by means of the OCI-r and SCL-90 r OC subscale, for 11 participants. Relating to the measures detected by psychotherapists, marginally significant improvements and lower scores were found in the Y-BOCS (I). An improvement in symptoms was noticed by 90.9% of the clinical sample; this was confirmed by 45.4% of the therapists, who claimed moderate progress in their patients. Conclusions: The data collected through standardized measurements at two different times, albeit relative to a small sample, assume relevance from a clinical point of view. In the literature, some studies document the worsening of OCD. However, in many studies, the type of treatment, the detection time, and the intervention period are not well-specified. These results confirm the effectiveness of CBT/ERP as an elective treatment for OCD through a specific intervention procedure.

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.

Two Reasoning Strategies in Patients With Psychological Illnesses

Hyper-emotion theory states that psychological disorders are conditions in which individuals experience emotions that are appropriate to the situation but inappropriate in their intensity. When these individuals experience such an emotion, they are inevitably compelled to reason about its cause. They therefore develop characteristic strategies of reasoning depending on the particular hyper-emotion they experience. In anxiety disorders (e.g., panic attack, social phobia), the perception of a disorder-related threat leads to hyper-anxiety; here, individuals' reasoning is corroboratory, adducing evidence that confirms the risk (corroboratory strategy). In obsessive-compulsive disorders, the threat of having acted in an irresponsible way leads to both hyper-anxiety and guilt; here, individuals' reasoning is refutatory, adducing only evidence disconfirming the risk of being guilty (refutatory strategy). We report three empirical studies corroborating these hypotheses. They demonstrate that patients themselves recognize the two strategies and spontaneously use them in therapeutic sessions and in evaluating scenarios in an experiment.

Causal role for inverse reasoning on obsessive-compulsive symptoms: Preliminary evidence from a cognitive bias modification for interpretation bias study

BACKGROUND AND OBJECTIVES

The inference-based approach (IBA) is a cognitive account of the genesis and maintenance of obsessive-compulsive disorder (OCD). According to the IBA, individuals with OCD are prone to using inverse reasoning, in which hypothetical causes form the basis of conclusions about reality. Several studies have provided preliminary support for an association between features of the IBA and OCD symptoms. However, there are currently no studies that have investigated the proposed causal relationship of inverse reasoning in OCD.

METHODS

In a non-clinical sample (N = 187), we used an interpretive cognitive bias procedure to train a bias towards using inverse reasoning (n = 64), healthy sensory-based reasoning (n = 65), or a control condition (n = 58). Participants were randomly allocated to these training conditions. This manipulation allowed us to assess whether, consistent with the IBA, inverse reasoning training increased compulsive-like behaviours and self-reported OCD symptoms.

RESULTS

Results indicated that compared to a control condition, participants trained in inverse reasoning reported more OCD symptoms and were more avoidant of potentially contaminated objects. Moreover, change in inverse reasoning bias was a small but significant mediator of the relationship between training condition and behavioural avoidance. Conversely, training in a healthy (non-inverse) reasoning style did not have any effect on symptoms or behaviour relative to the control condition.

LIMITATIONS

As this study was conducted in a non-clinical sample, we were unable to generalise our findings to a clinical population.

CONCLUSIONS

Findings generally support the IBA model by providing preliminary evidence of a causal role for inverse reasoning in OCD.

Inverse reasoning processes in obsessive-compulsive disorder

The inference-based approach (IBA) is one cognitive model that aims to explain the aetiology and maintenance of obsessive-compulsive disorder (OCD). The model proposes that certain reasoning processes lead an individual with OCD to confuse an imagined possibility with an actual probability, a state termed inferential confusion. One such reasoning process is inverse reasoning, in which hypothetical causes form the basis of conclusions about reality. Although previous research has found associations between a self-report measure of inferential confusion and OCD symptoms, evidence of a specific association between inverse reasoning and OCD symptoms is lacking. In the present study, we developed a task-based measure of inverse reasoning in order to investigate whether performance on this task is associated with OCD symptoms in an online sample. The results provide some evidence for the IBA assertion: greater endorsement of inverse reasoning was significantly associated with OCD symptoms, even when controlling for general distress and OCD-related beliefs. Future research is needed to replicate this result in a clinical sample and to investigate a potential causal role for inverse reasoning in OCD.

An experimental re-examination of the inferential confusion hypothesis of obsessive-compulsive doubt

BACKGROUND AND OBJECTIVES

The inferential confusion hypothesis postulates that obsessive doubt is perpetuated by a subjective form of reasoning characterized primarily by a distrust of reality and an overreliance on imagined possibilities. However, experimental evidence for this hypothesis may be compromised by a potential confound between type of information (reality vs. possibility) and its valence (danger vs. safety). In the present study we aimed to untangle this potential confound.

METHODS

Forty OCD and 40 non-clinical participants underwent two versions of the Inferential Processes Task (Aardema, F., et al. (2009). The quantification of doubt in obsessive-compulsive disorder. International Journal of Cognitive Therapy, 2, 188-205). In the original version, the reality-based information is congruent with the safety hypothesis, whereas the possibility-based information is congruent with the danger hypothesis. In the modified version incorporated in the present study, the reality-based information is congruent with the danger hypothesis, whereas the possibility-based information is congruent with the safety hypothesis.

RESULTS

Our findings did not support the inferential confusion hypothesis: both OCD and control participants changed their estimations of the probability of unwanted events based on the type of information they received (whether it conveyed danger or safety) regardless of whether it was framed as reality or possibility.

LIMITATIONS

The design of the present study does not lend itself to examining alternative explanations for the persistence of doubt in OCD.

CONCLUSIONS

The hypothesized inferential confusion in OCD requires further validation. It is particularly important to demonstrate that findings do not reflect a prudential reasoning strategy.

The relevance of maintaining and worsening processes in psychopathology

The states called "psychopathology" are very diverse, but Lane et al.'s single-process explanation does little to account for this diversity. Moreover, some other crucial phenomena of psychopathology do not fit this theory: the role of negative evaluations of conscious emotions, and the role of emotions without physiological correlates. And it does not consider the processes maintaining disorders.

How emotions affect logical reasoning: evidence from experiments with mood-manipulated participants, spider phobics, and people with exam anxiety

Recent experimental studies show that emotions can have a significant effect on the way we think, decide, and solve problems. This paper presents a series of four experiments on how emotions affect logical reasoning. In two experiments different groups of participants first had to pass a manipulated intelligence test. Their emotional state was altered by giving them feedback, that they performed excellent, poor or on average. Then they completed a set of logical inference problems (with if p, then q statements) either in a Wason selection task paradigm or problems from the logical propositional calculus. Problem content also had either a positive, negative or neutral emotional value. Results showed a clear effect of emotions on reasoning performance. Participants in negative mood performed worse than participants in positive mood, but both groups were outperformed by the neutral mood reasoners. Problem content also had an effect on reasoning performance. In a second set of experiments, participants with exam or spider phobia solved logical problems with contents that were related to their anxiety disorder (spiders or exams). Spider phobic participants' performance was lowered by the spider-content, while exam anxious participants were not affected by the exam-related problem content. Overall, unlike some previous studies, no evidence was found that performance is improved when emotion and content are congruent. These results have consequences for cognitive reasoning research and also for cognitively oriented psychotherapy and the treatment of disorders like depression and anxiety.

Cognitive bias in action: evidence for a reciprocal relation between confirmation bias and fear in children

BACKGROUND AND OBJECTIVES

Some cognitive models propose that information processing biases and fear are reciprocally related. This idea has never been formally tested. Therefore, this study investigated the existence of a vicious circle by which confirmation bias and fear exacerbate each other.

METHODS

One-hundred-and-seventy-one school children (8-13 years) were first provided with threatening, ambiguous, or positive information about an unknown animal. Then they completed a computerized information search task during which they could collect additional (negative, positive, or neutral) information about the novel animal. Because fear levels were repeatedly assessed during the task, it was possible to examine the reciprocal relationship between confirmation bias and fear.

RESULTS

A reciprocal relation of mutual reinforcement was found between confirmation bias and fear over the course of the experiment: increases in fear predicted subsequent increases in the search for negative information, and increases in the search for negative information further enhanced fear on a later point-in-time. In addition, the initial information given about the animals successfully induced diverging fear levels in the children, and determined their first inclination to search for additional information.

LIMITATIONS

As this study employed a community sample of primary school children, future research should test whether these results can be generalized to clinically anxious youth.

CONCLUSIONS

These findings provide first support for the notion that fearful individuals may become trapped in a vicious circle in which fear and a fear-related confirmation bias mutually strengthen each other, thereby maintaining the anxiety pathology.

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5

OBJECTIVE

Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample.

METHODS

Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity.

RESULTS

Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD.

CONCLUSIONS

The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.

"Will a Cuscus bite you, if he shows his teeth?" Inducing a fear-related confirmation bias in children by providing verbal threat information to their mothers

Confirmation bias refers to the inclination to selectively search for information that confirms the view that one holds. Research has shown that fearful individuals mainly seek information that confirms dangerousness of the dreaded stimulus or situation (i.e., verification), whereas they have less an eye for information that invalidates threat (i.e., falsification). It has been demonstrated that fear-related reasoning biases also occur in children, but little is known about where these biases originate from. The present study examined the role of mothers in the development of a fear-related confirmation bias in children. More precisely, it was tested whether mothers install such a reasoning bias in their children via verbal threat information. For this purpose, mothers of 52 children aged 9-12 years were provided with either threatening or positive information about a novel animal and then instructed to describe the animal to their child on the basis of a number of open-ended vignettes. Results indicated that mothers who received threat information about the novel animal displayed a fear-related confirmation bias: that is, they relied less on a falsification strategy than mothers who had heard the positive information. Most importantly, mothers passed the bias on to their children. More precisely, after the vignettes task, children of mothers who had received threat information also sought less information to invalidate the dangerousness of the animal than children of mothers who had received positive information.

Effects of verbal information on fear-related reasoning biases in children

The present study made an attempt to induce fear-related reasoning biases by providing children with negative information about a novel stimulus. For this purpose, non-clinical children aged 9-12 years (N=318) were shown a picture of an unknown animal for which they received either negative, ambiguous, positive, or no information. Then children completed a series of tests for measuring various types of reasoning biases (i.e., confirmation bias and covariation bias) in relation to this animal. Results indicated that children in the negative and, to a lesser extent, the ambiguous information groups displayed higher scores on tests of fear-related reasoning biases than children in the positive and no information groups. Altogether, these results support the idea that learning via negatively tinted information plays a role in the development of fear-related cognitive distortions in youths.

The feature-positive effect and hypochondriacal concerns

There is evidence to suggest that people have more problems with processing information that is absent (negative information) than with present (positive) information. This bias of overweighing positive and underweighing negative information has been termed the "feature-positive effect" (FPE). Typically, hypochondriasis is characterized by excessive focusing on bodily complaints (cf. positive information), and at the same time discarding negative medical test results (cf. negative information). It was explored whether the FPE is involved in this pattern. Fifty-three undergraduates completed a measure of hypochondriacal concerns and a general, domain-free test of the FPE. As expected, a positive correlation between the FPE and hypochondriacal concerns was observed. Implications for cognitive-behavioural theory are discussed.

Explaining medically unexplained symptoms-models and mechanisms

We summarize the psychological mechanisms that have been linked to the development and maintenance of medically unexplained symptoms (MUS). Many models postulate that patients with MUS misinterpret physical sensations and show other cognitive abnormalities (e.g., an over-exclusive concept of health) that play a major role in symptom development. While there is strong evidence for the role of cognitive aspects, there is less evidence for their interaction with perceptual features (e.g., perceptual sensitivity, lowered perceptual threshold). Modern neuroimaging techniques show that the expectation of symptoms leads to the activation of brain areas corresponding to symptom perception, while distraction from symptoms reduces brain activity in perception areas. The frequently postulated monocausal organic attribution for physical sensations by patients with MUS needs to be modified, as many patients report multiple symptom attributions, including psychological. Symptom attributions and causal models depend on memorized concepts, and so memory processes need to be investigated in more detail. Aberrations in memory processes not only offer a link to understanding perceptual processes, but are also involved in doctor-patient interaction. This encounter is characterized by unsuccessful medical reassurance, which again involves memory processes. We conclude that psychological mechanisms such as expectation, distraction, and memory processes need to be integrated with biological models to aid understanding of MUS.

Cognitive and perceptual variables in hypochondriasis and health anxiety: A systematic review

This review examined (a) whether hypochondriacal/health-anxious individuals hold distinct assumptions about health and illness, (b) if triggering these assumptions leads to increased hypochondriacal concerns, and (c) whether these individuals perceive their bodily sensations differently from others (i.e., experience greater somatosensory amplification). There was clear evidence that health anxiety is related dysfunctional health-related beliefs. Few studies have examined how hypochondriacal concerns are triggered, and inconsistent results emerged from those that have. Health anxiety is also associated with self-reported higher levels of somatosensory amplification. However, there was little evidence that individuals high in health anxiety are actually more accurate perceivers of the their own autonomic processes. Although the results generally supported the central tenets of the cognitive-behavioral model of hypochondriasis and health anxiety, further research will be necessary to determine whether these beliefs are specific to hypochondriasis and to identify any cognitive processes that may be unique to hypochondriasis.

The effect of emotion on interpretation and logic in a conditional reasoning task

The effect of emotional content on logical reasoning is explored in three experiments. Theparticipants completed a conditional reasoning task (If p, then q) with emotional and neutral contents. In Experiment 1, existing emotional and neutral words were used. The emotional value of initially neutral words was experimentally manipulated in Experiments 1B and 2, using classical conditioning. In all experiments, participants were less likely to provide normatively correct answers when reasoning about emotional stimuli, compared with neutral stimuli. This was true for both negative (Experiments 1B and 2) and positive contents (Experiment 2). The participants' interpretations of the conditional statements were also measured (perceived sufficiency, necessity, causality, and plausibility). The results showed the expected relationship between interpretation and reasoning. However, emotion did not affect interpretation. Emotional and neutral conditional statements were interpreted similarly. The results are discussed in light of current models of emotion and reasoning.

The role of responsibility and fear of guilt in hypothesis-testing

Recent theories argue that both perceived responsibility and fear of guilt increase obsessive-like behaviours. We propose that hypothesis-testing might account for this effect. Both perceived responsibility and fear of guilt would influence subjects' hypothesis-testing, by inducing a prudential style. This style implies focusing on and confirming the worst hypothesis, and reiterating the testing process. In our experiment, we manipulated the responsibility and fear of guilt of 236 normal volunteers who executed a deductive task. The results show that perceived responsibility is the main factor that influenced individuals' hypothesis-testing. Fear of guilt has however a significant additive effect. Guilt-fearing participants preferred to carry on with the diagnostic process, even when faced with initial favourable evidence, whereas participants in the responsibility condition only did so when confronted with an unfavourable evidence. Implications for the understanding of obsessive-compulsive disorder (OCD) are discussed.

Fear of guilt from behaving irresponsibly in obsessive-compulsive disorder

Previous cognitive models of obsessive-compulsive disorder (OCD) propose that inflated responsibility plays a key role in the maintenance of symptoms (Behav.Res.Ther. 28 (1985) 571). In this manuscript, we propose that this thesis may be improved by emphasizing that instead, OCD may be characterized by a fear of guilt that would result from behaving irresponsibly and/or from not behaving responsibly. We believe that this concept provides a better explanation for the anxious and fearful nature of OCD than do more traditional conceptualizations of inflated responsibility. We support this idea with empirical evidence and propose that OCD symptoms are consistent with patients acting in a prudential mode because of their fears of guilt.

Role of responsibility in conditional reasoning

A series of recent studies showed that facilitation on the Wason Selection Task could be produced by perceived utilities. The present work was aimed at testing whether a similar factor could also be involved in human reasoning performance in the context of responsibility. We supposed that the motivation of the subject assuming responsibility is affected by normative goals. These goals prescribe the actions and the results to be achieved, also considering the different social roles. In this experiment the responses of different groups of subjects (N = 270) to a selection task were compared in two different conditions involving different responsibility contexts. The results show that the subjects' strategies in searching for possible violators depended on the condition (responsibility vs no responsibility). In particular, only in the context of responsibility were the performances elicited by conditional rules characterised by a falsification strategy.

If you suffer from a headache, then you have a brain tumour: domain-specific reasoning 'bias' and hypochondriasis

We explored whether hypochondriacal patients selectively search for threat-confirming information when asked to judge the validity of conditional rules in the context of general and health threats. We also explored several factors that may underly participants' information selection (e.g., believability of the rule). Hypochondriacal patients (n = 20) and healthy controls (n = 20) were presented with modified Wason Selection Tasks (WSTs). The WSTs contained safety rules and danger rules. In the context of general threat, both groups of participants adopted a verificationistic strategy in the case of danger rules and a Popperian strategy in the case of safety rules. Importantly, only hypochondriacal persons showed a similar threat-confirming reasoning pattern in the context of health threat. The latter finding contrasts with the earlier study of de Jong et al. (1998) [de Jong, P. J., Haenen, M.-A., Schmidt, A., & Mayer, B. (1998a). Hypochondriasis: the role of fear-confirming reasoning. Behaviour Research and Therapy, 36, 65-74; de Jong, P. J., Mayer, B., van der Hijden, B., Bögels, S., & van den Hout, M. (1998b). Better safe than sorry: reasoning with conditionals in the context of threat. Submitted for publication.] in which both hypochondriacs and healthy controls showed a threat-confirming strategy in the domain of health threat. The WSTs in that study however, contained a (unintended) worry manipulation ("after hearing this, you get worried"), which might have induced a reasoning strategy in controls that is normally restricted to hypochondriacs. Taken together, the present results sustain the idea that the perception of threat activates a better safe than sorry strategy. In the case of phobic threats, such a reasoning strategy immunizes against refutation of phobic convictions.

Perceptual and memory biases for health-related information in hypochondriacal individuals

Problematic health concerns characteristic of hypochondriasis may be better understood with the aid of cognitive, information processing theories. We investigated whether hypochondriacal individuals show perceptual and explicit memory biases favoring health-related information. A clinical sample of hypochondriacs (n=18) and healthy controls (n=22), and a sample of hypochondriacal (n=22) and nonhypochondriacal (n=67) patients referred for Holter monitoring, completed a computerized test of perceiving difficult-to-read words and then an encoding task followed by recall of those words. Contrary to our prediction, hypochondriacal individuals in the clinical sample did not perceive more health-related words than words not related to health. Hypochondriacal individuals in the Holter-monitoring sample showed an unexpected bias against reporting health-related words. Social class may account for some of the group differences in this sample. Hypochondriacal individuals in both samples showed better memory for health-related than nonhealth words.