A taxometric analysis of health anxiety

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Illness Anxiety Disorder: A Review of the Current Research and Future Directions

PURPOSE OF REVIEW

We review recent evidence on Illness Anxiety Disorder (IAD), including risk factors and precipitants, diagnostic classification, clinical characteristics of the disorder, and assessment and treatment in both children and adults.

RECENT FINDINGS

IAD places a substantial burden on both individuals and society. Despite its impact, understanding of the disorder is lacking and debates remain about whether IAD should be classified as an anxiety disorder and whether it is distinct from Somatic Symptom Disorder. Cognitive behavioural therapy (CBT) is an effective treatment for IAD and there are multiple validated measures of health anxiety available. However, research on health anxiety in children and youth is limited. IAD is chronic, and debilitating, but when identified, it can be effectively treated with CBT. Research using DSM-5 IAD criteria is lacking, and more research is needed to better understand the disorder, particularly in children and youth.

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.

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.

The level of health anxiety before and during the COVID-19 pandemic

BACKGROUND

Concerns about disease and an increase in health anxiety levels are expected consequences of the COVID-19 pandemic. However, there have been few longitudinal studies of health anxiety in the general population during this time period. The aim of this study was to examine health anxiety levels before and during the COVID-19 pandemic in an adult, working population in Norway.

MATERIAL AND METHODS

This study included 1012 participants aged 18-70 years with one or more measurements of health anxiety (1402 measurements total) from the pre-pandemic period (2015 to March 11, 2020) and/or during the COVID-19 pandemic (March 12, 2020 to March 31, 2022). Health anxiety was measured with the revised version of the Whiteley Index-6 scale (WI-6-R). We estimated the effect of the COVID-19 pandemic on health anxiety scores with a general estimation equation analysis, and age, gender, education, and friendship were included in subgroup analyses.

RESULTS

We found no significant change in health anxiety scores during the COVID-19 pandemic compared to the pre-pandemic period in our adult, working population. A sensitivity analysis restricted to participants with two or more measurements showed similar results. Moreover, the effect of the COVID-19 pandemic on health anxiety scores was not significant in any subgroup analysis.

CONCLUSION

Health anxiety remained stable, with no significant change observed between the pre-pandemic period and the first 2 years of the COVID-19 pandemic in an adult, working population in Norway.

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.

The association between health anxiety, physical disease and cardiovascular risk factors in the general population – a cross-sectional analysis from the Tromsø study: Tromsø 7

Background

Health anxiety (HA) is defined as a worry of disease. An association between HA and mental illness has been reported, but few have looked at the association between HA and physical disease.

Objective

To examine the association between HA and number of diseases, different disease categories and cardiovascular risk factors in a large sample of the general population.

Methods

This study used cross-sectional data from 18,432 participants aged 40 years or older in the seventh survey of the Tromsø study. HA was measured using a revised version of the Whiteley Index-6 (WI-6-R). Participants reported previous and current status regarding a variety of different diseases. We performed exponential regression analyses looking at the independent variables 1) number of diseases, 2) disease category (cancer, cardiovascular disease, diabetes or kidney disease, respiratory disease, rheumatism, and migraine), and 3) cardiovascular risk factors (high blood pressure or use of cholesterol- or blood pressure lowering medication).

Results

Compared to the healthy reference group, number of diseases, different disease categories, and cardiovascular risk factors were consistently associated with higher HA scores. Most previous diseases were also significantly associated with increased HA score. People with current cancer, cardiovascular disease, and diabetes or kidney disease had the highest HA scores, being 109, 50, and 60% higher than the reference group, respectively.

Conclusion

In our general adult population, we found consistent associations between HA, as a continuous measure, and physical disease, all disease categories measured and cardiovascular risk factors.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Distribution of health anxiety in a general adult population and associations with demographic and social network characteristics

BACKGROUND

Health anxiety (HA) is associated with increased risk of disability, increased health care utilization and reduced quality of life. However, there is no consensus on which factors are important for the level of HA. The aim of this study was to explore the distribution of HA in a general adult population and to investigate whether demographic and social factors were associated with HA.

METHODS

This study used cross-sectional data from the seventh Tromsø study. A total of 18 064 participants aged 40 years or older were included in the analysis. The six-item Whiteley Index (WI-6) with a 5-point Likert scale was used to measure HA. Sociodemographic factors included age, sex, education, household income, quality of friendship and participation in an organized activity.

RESULTS

HA showed an exponential distribution among the participants with a median score of 2 points out of 24 points. In total, 75% had a total score of 5 points or less, whereas 1% had a score >14 points. Education, household income, quality of friendship and participation in organized activity were significantly associated with HA. The variable quality of friendship demonstrated the strongest association with HA.

CONCLUSION

Our study showed an exponential distribution of HA in a general adult population. There was no evident cut-off point to distinguish participants with severe HA based on their WI-6 score, indicating the importance of analysing HA as a complex, continuous construct. HA demonstrated strong associations with quality of friendship and participation in an organized activity.

Ethnic and migration-related inequalities in health anxiety: A systematic review and meta-analysis

Background

Health anxiety exists on a continuum ranging from the absence of health awareness to the obsessive fear of having a serious illness despite reassurance. Its pathological manifestation can be diagnosed as hypochondriacal or illness anxiety or somatic symptom disorder. Health anxiety is associated with psychological distress and adverse life events, among others, and leads to considerable economic burden. Compared to the majority population, migrants, and ethnic minorities often face major health inequalities. Several mental illnesses and psychosomatic complaints are more common among these groups. To date, potential ethnic and migration-related inequalities in health anxiety have not been clearly described. However, they are of high relevance for the provision of adequate health care of this diverse and potentially vulnerable group. Thus, we conducted a systematic review and meta-analysis of health anxiety in migrants and ethnic minorities.

Methods

A systematic literature search of PubMED, Web of Science, PsycINFO, and PSYNDEX was conducted, covering all studies published until 1st of December 2021. Studies were selected if they employed validated measurement tools of health anxiety and examined migrants and/or ethnic minorities in comparison with the majority population. Meta-analytic methods were applied by using a random-effect model. The study quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool (EPHPP).

Results

We identified 18 studies from 445 studies initially screened. Of these, 14 studies conducted in North America with a total number of 5,082 study participants were included in the meta-analysis. The pooled effect size indicated a higher risk of health anxiety in migrants and ethnic minorities compared to the majority population (OR 1.39, 95%-CI 1.01-1.92). The results proved not to be robust according to publication bias (adjusted OR 1.18, 95%-CI 0.83-1.69) and fail-safe N (2/3 < benchmark N = 75) and are limited due to heterogeneity (I 2 = 57%), small sample sizes and an overall low quality of included studies.

Conclusion

To address the diversity of migrants and ethnic minorities, inter-sectional approaches across different countries are needed in research to shed further light on social inequalities in health anxiety linked to migration.

Systematic review registration

PROSPERO, registration number CRD42022298458.

Application of unified protocol as a transdiagnostic treatment for emotional disorders during COVID-19: An internet-delivered randomized controlled trial

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has been an emotionally challenging time, especially for young adults. It is associated with a substantial increase in the prevalence of mental health problems, negative symptoms, and stressful experiences that compromise well-being. In low-income countries, internet-delivered psychological services could have a remarkable impact on the population’s mental health, given the lack of mental health professionals.

AIM

To investigate the efficacy of internet-delivered cognitive-behavior therapy (CBT)-transdiagnostic intervention for adults with emotional disorders.

METHODS

In this internet-delivered randomized controlled trial, 102 students with an emotional disorder (mean age = 28.20 years, standard deviation = 5.07) were randomly allocated to receive unified protocol (UP) (n = 51) or treatment as the usual intervention. Following a semi-structured clinical interview, participants completed an online survey including the Overall Anxiety Severity and Impairment Scale, Overall Depression Severity and Impairment Scale, Difficulties in Emotion Regulation Scale, Positive and Negative Affect Schedule, and Emotional Style Questionnaire.

RESULTS

The participants showed a high degree of adherence. In total, 78% (n = 40) of the experimental group participants completed the UP treatment. Considering the intention to treat procedure, the results of the analysis of covariance indicated that participants who received UP showed statistically significant changes in depression symptoms [Cohen’s d = -1.50 with 95% confidence interval (CI): -1.90 to -1.10], anxiety (Cohen’s d = -1.06 with 95%CI: -1.48 to -0.65), difficulties with emotion regulation (Cohen’s d = -0.33 with 95%CI: -0.7 to -0.06), positive affect (Cohen's d = 1.27 with 95%CI: 0.85 to 1.68), negative affect (Cohen’s d= -1.04 with 95%CI: -1.46 to -0.63), and healthy emotionality (Cohen’s d = 0.53 with 95%CI: 0.09 to 0.13) compared with the control group.

CONCLUSION

This study’s findings highlight the potential value of transdiagnostic internet-delivered programs for young adults with an emotional disorder during the COVID-19 pandemic, and expand the research examining emotional well-being improvements resulting from CBT-transdiagnostic interventions. The findings suggest that UP, which generally concentrates on reducing negative effects, can increase positive effects.

The Portrait of Cyberchondria-A Cross-Sectional Online Study on Factors Related to Health Anxiety and Cyberchondria in Polish Population during SARS-CoV-2 Pandemic

The SARS-CoV-2 pandemic has served as a magnifying glass for cyberchondria, while the internet emerged as one of the main sources of medical information and support. The core ambition of this study was to estimate the level of cyberchondria and describe the socio-demographic, clinical and pandemic-related factors affecting its severity amid the SARS-CoV-2 pandemic. A cross-sectional study was performed between 16 May 2020 and 29 December 2020 in Poland within a sample of 538 adult internet users. The online survey tool included a Polish adaptation of the Cyberchondria Severity Scale (CSS-PL) and the Short Health Anxiety Inventory (SHAI), complemented with a set of questions covering sociodemographic, clinical and pandemic-related factors. Participants were clustered according to severity of health anxiety and cyberchondria symptoms. The performed binary logistic regression indicated professional inactivity, having a chronic mental disorder and subjectively limited access to healthcare due to COVID-19 to be key determinants of severe health anxiety and cyberchondria. Cyberchondria might be a remarkable public health issue as large proportion of respondents from the analyzed sample population of internet users met the criteria for severe symptoms. Key determinants of intense cyberchondria corresponded with employment stability, mental resilience and accessibility of healthcare services, which could be greatly challenged amid the pandemic.

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

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

Relationship Between Dry Eye Disease and Emotional Disorder: The Mediating Effect of Health Anxiety

Objective

This study aims to investigate the relationship between dry eye disease (DED) and anxiety, as well as DED and depression. Additionally, the influence of health anxiety (HA) on this relationship was determined.

Methods

A total of 206 patients with DED were recruited from Tianjin Medical University Eye Hospital clinic and surveyed using demographic questionnaires, the Ocular Surface Disease Index (OSDI), Hospital Anxiety and Depression Scale (HADS), and Short Health Anxiety Inventory (SHAI). Additionally, they were examined using Keratograph 5M and assessed for DED by corneal fluorescein staining. Regression analysis and the bootstrap method were used to investigate the influence of HA on the relationship between DED and emotional disorders.

Results

Among the 206 patients with DED, 52 (25.24%) and 56 (27.18%) patients showed depression and anxiety, respectively. The OSDI score and HA were positively correlated with depression and anxiety (P &lt; 0.01). The direct effects of OSDI on depression and anxiety were significant (95% confidence interval [CI]: 0.017–0.069; 0.008–0.060). Additionally, the bootstrap test showed significant mediating effects of HA (95% CI: 0.001–0.016; 0.003–0.021). The results suggested that the severity of DED symptoms, as measured by the OSDI score, affected anxiety and depression by a direct and an indirect pathway mediated by HA.

Conclusions

We found a significant correlation between DED and anxiety and depression. Moreover, HA was a mediator of the relationship between DED symptoms and anxiety and depression.

Health anxiety is an important driver of healthcare use

Background

Healthcare use is increasing, and health anxiety (HA) is recognized as an important associated factor. Previous research on the association between HA and healthcare use has mostly explored HA as a dichotomous construct, which contrasts the understanding of HA as a continuous construct, and compared healthcare use to non-use. There is a need for studies that examine the association between healthcare use and the continuum of HA in a general population.

Aim

To explore the association between HA and primary, somatic specialist and mental specialist healthcare use and any differences in the association by level of healthcare use.

Methods

This study used cross-sectional data from the seventh Tromsø study. Eighteen thousand nine hundred sixty-seven participants aged 40 years or older self-reported their primary, somatic specialist and mental specialist healthcare use over the past 12 months. Each health service was categorized into 5 groups according to the level of use. The Whiteley Index-6 (WI-6) was used to measure HA on a 5-point Likert scale, with a total score range of 0–24. Analyses were conducted using unconstrained continuation-ratio logistic regression, in which each level of healthcare use was compared with all lower levels. Morbidity, demographics and social variables were included as confounders.

Results

HA was positively associated with increased utilization of primary, somatic specialist and mental specialist healthcare. Adjusting for confounders, including physical and mental morbidity, did not alter the significant association. For primary and somatic specialist healthcare, each one-point increase in WI-6 score yielded a progressively increased odds ratio (OR) of a higher level of use compared to all lower levels. The ORs ranged from 1.06 to 1.15 and 1.05 to 1.14 for primary and somatic specialist healthcare, respectively. For mental specialist healthcare use, the OR was more constant across levels of use, ranging between 1.06 and 1.08.

Conclusions

In an adult general population, HA, as a continuous construct, was significantly and positively associated with primary, somatic specialist and mental healthcare use. A small increase in HA was associated with progressively increased healthcare use across the three health services, indicating that the impact of HA is more prominent with higher healthcare use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07529-x.

Metacognitive Beliefs about Uncontrollability Relate Most Strongly to Health Anxiety among U.S.-based non-Latinx White Primary Care Patients: Comparing Strength of Relations with U.S.-based non-Latinx Black and Latinx Primary Care Patients

Metacognitive beliefs have emerged as important to health anxiety, particularly beliefs that health-related thoughts are uncontrollable. Preliminary research examining generalized worry indicates uncontrollability beliefs relate more strongly to anxiety among U.S.-based self-identifying White relative to Black college students. The present study sought to extend that line of research by examining if metacognitive beliefs about the uncontrollability of health-related thoughts differentially relate to health anxiety among self-identifying non-Latinx Black (n = 123), Latinx (n = 104), and non-Latinx White (n = 80) U.S.-based primary care patients. As predicted, although positive associations were seen across all three groups, beliefs that health-related thoughts are uncontrollable more strongly related to health anxiety among White patients compared to both Black and Latinx patients. Those differential relations held in multivariate analyses while statistically controlling for positive depression screening status, generalized anxiety symptom severity, and medical morbidity. Although the effect size surrounding the differential relations was small in magnitude, the present results further support the notion that metacognitive beliefs about uncontrollability relate less strongly to anxiety among U.S.-based ethnoracial minorities compared to White individuals. Potential reasons for the differential relations are discussed, along with additional areas for future research.

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.

Predicting PTSS in general population during COVID-19 pandemic: The mediating role of health anxiety

BACKGROUND

Despite health anxiety (HA) is associated with higher incidence of anxiety disorders, no studies have examined the association between this variable and the increased levels of Post-Traumatic Stress Symptoms (PTSS) reported during COVID pandemic.

METHODS

This study was conducted online between April and May 2020. Data were collected from 468 men and women from the Spanish general population. Sociodemographic and COVID-19-related data, health anxiety, PTSS, fear of becoming infected, social support, sleep problems and past/current psychological/psychiatric history were assessed. The mediating effect of HA when predicting PTSS was explored with mediational analyses. Moderated mediational analyses were also performed to test if receiving psychological treatment during pandemic changes the mediating effect of HA.

RESULTS

Prevalence of PTSS was higher in high-scorers in HA (p<.01). High HA was also more likely to be reported by women, individuals with sleep problems, frequently fear of getting infected, and those who have previously received psychological treatment (p<.01). HA mediates the relationship between PTSS and the following predictors of PTSS: sleep problems, psychiatric history and fear of getting infected. Being under psychological treatment did not moderate the mediating effect of health anxiety.

LIMITATIONS

Further longitudinal studies with bigger sample sizes are needed to examine the causal relationship between HA and PTSS after COVID-19 pandemic.

CONCLUSIONS

Our findings suggest that HA could influence the psychological consequences of the pandemic. Screening of HA could be useful to identify people with heightened risk of developing PTSS during pandemic.

Psychometric Validation of the Indonesian Version of the Fear of COVID-19 Scale: Personality Traits Predict the Fear of COVID-19

The coronavirus disease-2019 (COVID-19) pandemic is a global health crisis that has generated fear and negative psychological consequences. The present study evaluated the validity and factor structure of Fear of COVID-19 Scale (FCV-19S) among a sample from the general Indonesian population. The English version of the FCV-19S was translated and back-translated into Indonesian language, followed by a pilot study. Using convenience sampling method, a total of 728 participants completed an online survey distributed on various social media platforms. The survey included the FCV-19S, personality traits (neuroticism and extraversion), Positive and Negative Affect Scale (PANAS), Generalized Anxiety Disorder Scale (GAD-7), and the nine-item Patient Health Questionnaire (PHQ-9). The Indonesian FCV-19S had very good internal consistency (Cronbach's alpha and McDonald's omega) and composite reliability (alpha = 0.88, omega = .86, composite reliability = .87). Maximum likelihood confirmatory factor analysis (CFA) was conducted to test construct validity (χ 2/df = 2.51, CFI = .984, SRMR = .028, PCLOSE = .15 > .05, RMSEA = .06, 90% CI [.03, .09]). As for criterion-related validity, the FCV-19S score positively correlated with the score on PHQ-9, GAD-7, negative affect, and neuroticism and negatively correlated with extraversion. Negative affect was identified as the most important predictor of the fear of COVID-19. Personality traits also predicted the fear of COVID-19. The findings provide evidence that the FCV-19S is a reliable and valid instrument for assessing fear generated by COVID-19 among a healthy Indonesian-speaking population.

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.

Health Anxiety and Its Correlations with Self-Perceived Risk and Attitude on COVID-19 among Malaysian Healthcare Workers during the Pandemic

Healthcare workers (HCW) are exposed to health-related anxiety in times of pandemic as they are considered to have a high risk of being infected whilst being the vital workforce to manage the outbreak. This study determined the factors that influence health anxiety and its extent in correlations with perceived risk, knowledge, attitude, and practice of HCW. A cross-sectional online survey was conducted on a total of 709 HCW from both public and private healthcare facilities who completed a set of questionnaires on sociodemographic data, knowledge, attitude, and practice of HCW on COVID-19, and health anxiety traits assessed using the short version Health Anxiety Inventory (HAI). Multiple linear regression (adjusted R² = 0.06) revealed respondents with higher perceived risk for COVID-19 significantly predicted higher HAI scores (beta 1.281, p < 0.001, 95%, CI: 0.64, 1.92), and those with a higher cautious attitude towards COVID-19 significantly predicted higher HAI scores (beta 0.686, p < 0.001, 95%CI: 0.35, 1.02). Healthcare workers’ perceived risk and cautious attitude towards COVID-19 might be potentially influenced by management of the sources and approaches to the dissemination of information of the pandemic. The implementation of certain measures that minimize the infection risk and its related anxiety is important to preserve both their physical and psychological wellbeing.

What Psychological Factors Make Individuals Believe They Are Infected by Coronavirus 2019?

Background: We previously showed, by means of an online-based survey, that the belief of being infected by coronavirus disease 2019 (COVID-19) acted as a nocebo and predicted higher perception of symptoms similar to COVID-19 symptoms. However, there is little known about the psychological mechanisms that give rise to beliefs such as certainty of being infected by COVID-19, and this was investigated in the present study. Objective: Using the same data from the previous online survey with the same research team, we further investigated whether certainty of being infected by COVID-19 is associated with age, sex, health anxiety, and/or personality traits. Methods: Respondents (N = 375) filled out an online survey with 57 questions about symptoms similar to COVID-19, certainty of being infected by COVID-19, anxiety, stress, health anxiety, and personality dimensions (based on the five-factor model of personality). Results: Higher levels of conscientiousness and health anxiety were independently associated with certainty of being infected by COVID-19. The model predicted 29% of the variance in certainty of being infected by COVID-19. Conclusion: Being conscientious and worried about health issues were associated with the belief of being infected by COVID-19. Such finding may have implications for health care personnel who provide COVID-19 testing or consulting services to general population, as individuals high in these traits may over-report COVID-like symptoms. Theoretically, these findings point to psychological factors that may increase nocebo and possibly placebo effects. Clinically, the findings suggest that individuals high in conscientiousness and health anxiety may be more likely to over-report their bodily experiences.

Perceived vulnerability to disease, knowledge about COVID-19, and changes in preventive behavior during lockdown in a German convenience sample

The COVID-19 pandemic has called worldwide for strong governmental measures to contain its spread, associated with considerable psychological distress. This study aimed at screening a convenience sample in Germany during lockdown for perceived vulnerability to disease, knowledge about COVID-19, symptoms of depression and anxiety, and behavioral responses. In an online survey, 1358 participants completed the perceived vulnerability to disease scale (PVD), the Patient Health Questionnaire (PHQ-4), and questionnaires on knowledge about COVID-19 and self-perceived change in behaviors in response to COVID-19. Lower and upper quartiles of the PVD were used to classify individuals into low and high PVD. A confirmatory factor analysis supported three factors representing risk, preventive and adaptive behavior as behavioral responses to COVID-19 lockdown. A structural equation model showed that the score of the knowledge scale significantly predicted the self-reported increase in adaptive and preventive behavior. The score in the PVD-subscale Perceived Infectability predicted a self-reported increase in preventive behavior, whereas the Germ Aversion score predicted a self-reported increase in preventive and a decrease in risk behavior. The score in PHQ-4 predicted a higher score in the perceived infectability and germ aversion subscales, and a self-reported decrease in adaptive behavior. Low-, medium- and high-PVD groups reported distinct patterns of behavior, knowledge, and mental health symptoms. This study shows that perceived vulnerability to disease is closely linked to preventive behaviors and may enhance adaptation to COVID-19 pandemic.

Health Anxiety Predicts the Perceived Dangerousness of COVID-19 over and above Intrusive Illness-Related Thoughts, Contamination Symptoms, and State and Trait Negative Affect

This study sought to evaluate the specificity of health anxiety, relative to other forms of psychopathology, in perceptions of COVID-19 as dangerous. Measures of health anxiety, COVID-19 perceived dangerousness, negative affect, anxiety, depression, stress, contamination-related obsessions and compulsions, and intrusive illness-related thoughts were administered online to 742 community individuals during the Italian national lockdown. Results showed that, after controlling for demographic variables and other internalizing problems, health anxiety was the single most important factor associated with the perceived dangerousness of COVID-19. Moreover, a comparison between the current sample's scores on various symptom measures and scores from prepandemic Italian samples revealed that, whereas other internalizing symptoms increased by a large or very large magnitude during the pandemic, levels of health anxiety and negative affect increased by a medium amount. This result may indicate that health anxiety is relatively trait-like, increasing the likelihood that our correlational data support the model of health anxiety as a vulnerability rather than an outcome. Together, these results indicate that health anxiety may be a specific risk factor for COVID-related maladjustment and support the distinction of health anxiety from other psychological problems.

Health Anxiety and Its Correlates in the General Chinese Population During the COVID-19 Epidemic

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has had an adverse impact on the mental health of the general population. This study aimed to investigate the prevalence and correlates of health anxiety (HA) in the general Chinese population to inform psychological interventions in COVID-19-affected areas. Methods: We conducted an online survey of the general population in mainland China between 6 and 17 February 2020 (N = 1,450, 69.79% female; mean age = 37.5 ± 9.1 years). The Whiteley Index-7 (WI-7), COVID-19 knowledge quiz (CKQ), Generalised Anxiety Disorder scale (GAD-7), Patient Health Questionnaire Depression Scale (PHQ-9), and socio-demographic information were surveyed using the Questionnaire-Star program. Results: The prevalence of HA, depression and anxiety were 47.3, 31.3, and 35.7%, respectively. The WI-7 score showed a significant association with age, education level, income, occupation, chronic disease and daily time focused on COVID-19. On binary logistic regression analysis, individuals with masters or higher qualification degree [odds ratio (OR) = 0.632)], older age (OR = 0.981), 2-4 h daily time focused on COVID-19 (OR = 0.684), healthcare workers (OR = 0.749, p = 0.046) and those with more COVID-19 related knowledge (OR = 0.785) showed a significantly negative association with HA. Chronic disease (OR = 1.962), depression (OR = 1.05) and anxiety (OR = 1.228) were significant risk factors for HA. Conclusions: HA was highly prevalent among the general population during the early stages of the COVID-19 outbreak. More than two-fifths of the respondents had obvious HA. Chronic disease, depression and anxiety were risk factors for HA; psychological interventions offered during the pandemic should pay particular attention to these individuals.

Intolerance of uncertainty as a factor linking obsessive-compulsive symptoms, health anxiety and concerns about the spread of the novel coronavirus (COVID-19) in the United States

The novel coronavirus disease (COVID-19) has had a significant impact on public health, economic activity, and mental health as it spread across the globe. Research from past pandemics links excessive anxiety about illness-related threats with symptoms of health anxiety and obsessive-compulsive disorder (OCD). In the present study, we investigated whether intolerance of uncertainty (IU), a psychological vulnerability factor involved in both OCD and health anxiety, accounts for a portion of the relationship between these symptoms and fear of COVID-19 during the early stages of the outbreak in the Unites States. We administered measures of concern about the spread of COVID-19 (Coronavirus Threat Scale; CTS), health anxiety, and OCD symptoms to a large sample of community adults in the United States (n = 738) recruited through Amazon MTurk. Results revealed that concern about COVID-19 was moderately and positively correlated with both OCD and health anxiety symptoms, as well as IU. Moreover, regression analyses found that IU partially accounted for the connections between concern about the spread of COVID-19 and OCD and health anxiety symptoms. These results highlight IU as a potential mechanism connecting OCD and health anxiety to anxiety about pandemic threats. Clinical implications, limitations, and future directions for research are discussed.

Health Anxiety Predicts Postponing or Cancelling Routine Medical Health Care Appointments among Women in Perinatal Stage during the Covid-19 Lockdown

To avoid spreading the Corona Virus Disease 2019 (COVID-19), health authorities have forced people to reorganize their working and private lives and to avoid open and public spaces as much as possible. This has also been the case for women both during pregnancy and after delivery. Here, we investigated the associations between subjective beliefs in risk of infections and health anxiety, depression, stress, and other perinatal dimensions. To this end, we assessed 103 women (mean age: 28.57 years) during pregnancy and after delivery. They completed a series of questionnaires covering sociodemographic information, perinatal information, health anxiety, post-partum depression, and stress. Sixty-six participants (64.1%) were in the pre-partum stage, and 37 (35.9%) were post-partum. Health anxiety was unrelated to depression or stress. Knowing and being close to infected people was associated with higher health anxiety. Strict following of the safety recommendations was associated with greater health anxiety, depression, and stress. Postponing or cancelling routine medical check appointments was observed among participants with high health anxiety scores. Higher illness severity, overall health anxiety scores, and lower stress scores predicted those participants who postponed or cancelled their routine medical check appointments. Post-partum stage and a larger number of children were associated with higher stress scores, but not with depression or stress. The results are of practical and clinical importance; it appears that health anxiety, which is to say fear of getting infected with COVID-19 during pregnancy or at the post-partum stage, was associated with postponing or cancelling routine medical check appointments, but not with stress or depression.

Emotional and Behavioral Consequences of the COVID-19 Pandemic: The Role of Health Anxiety, Intolerance of Uncertainty, and Distress (In)Tolerance

The COVID-19 pandemic represents a worldwide threat to mental health. To optimize the allocation of health care resources, research on specific vulnerability factors, such as health anxiety, intolerance of uncertainty, and distress (in)tolerance, and particularly their effect on the time course of SARS-CoV-2 related anxiety appears crucial for supporting high risk groups suffering from elevated mental distress during the pandemic. N = 887 participants (78.4% female; Mage = 38.15, SD = 17.04) completed an online survey in Germany (April to mid-May 2020), comprising measures of SARS-CoV-2 related anxiety, health anxiety, safety and preventive behavior, intolerance of uncertainty, and distress intolerance. Higher levels of health anxiety pre and during COVID-19 were associated with an initially intensified increase (b = 1.10, p < 0.001), but later on a more rapid dampening (b = -0.18, p < 0.001) of SARS-CoV-2 related anxiety. SARS-CoV-2 related preventive behavior was intensified by both pre (b = 0.06, p = 0.01) and during (b = 0.15, p < 0.001) COVID-19 health anxiety, while reassurance behavior only was associated with health anxiety during COVID-19 (b = 0.14, p < 0.001). Distress intolerance and intolerance of uncertainty did not moderate the relationship between health anxiety and SARS-CoV-2 related anxiety and behavior. The results suggest detrimental effects of health anxiety on the emotional and behavioral response to virus outbreaks.

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.

Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: Which factors are related to coronavirus anxiety?

According to cognitive-behavioral models, traits, triggering events, cognitions, and adverse behaviors play a pivotal role in the development and maintenance of health anxiety. During virus outbreaks, anxiety is widespread. However, the role of trait health anxiety, cyberchondria, and coping in the context of virus anxiety during the current COVID-19 pandemic has not yet been studied. An online survey was conducted in the German general population (N = 1615, 79.8 % female, Mage = 33.36 years, SD = 13.18) in mid-March 2020, which included questionnaires on anxiety associated with SARS-CoV-2, trait health anxiety, cyberchondriaPandemic (i.e. excessive online information search), and emotion regulation. The participants reported a significantly increasing virus anxiety in recent months (previous months recorded retrospectively), especially among individuals with heightened trait health anxiety. CyberchondriaPandemic showed positive correlations with current virus anxiety (r = .09-.48), and this relationship was additionally moderated by trait health anxiety. A negative correlation was found between the perception of being informed about the pandemic and the current virus anxiety (r=-.18), with adaptive emotion regulation being a significant moderator for this relationship. The findings suggest that trait health anxiety and cyberchondria serve as risk factors, whereas information about the pandemic and adaptive emotion regulation might represent buffering factors for anxiety during a virus pandemic.

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.

Health anxiety in medical employees: A multicentre study

Objective

The aim of this study was to explore health anxiety (HA) in a sample of hospital medical employees and to identify factors that influence HA.

Methods

A consecutively recruited sample of 1702 medical employees with or without HA was obtained from 13 hospitals across China. Participants’ demographic and clinical characteristics were collected using a standardized protocol and data collection procedure. Subjects were divided into a HA and non-HA group according to their scores on the Chinese version of the Short Health Anxiety Inventory. Comparisons between groups were conducted and binary logistic regression was used to identify risk factors of HA.

Results

Total HA prevalence was 30.14%. There were significant differences between the HA and non-HA groups in number of working years, hospital category, sex, marital status, family income, personality, physical disease and education degree. Working in a specialist hospital, being female, being married, low income, introversion, graduate education or above and presence of physical disease were risk factors of HA.

Conclusions

HA is common in medical employees. More investigation of the long-term impact of HA is warranted.

Validation of the Chinese version of the Health Cognitions Questionnaire in Chinese college students

PURPOSE

The cognitive behavioral model is considered the most comprehensive for explaining the pathogenesis of health anxiety (HA). The model proposes 4 dysfunctional beliefs that play a vital role in developing and sustaining HA: a) the likelihood of contracting or having an illness, b) awfulness of the illness, c) difficulty coping with illness, and d) inadequacy of medical services. The Health Cognitions Questionnaire (HCQ), widely used in English populations, was developed for assessing these core cognitions. As HA is a growing problem in China, we translated the HCQ into a Chinese version (CHCQ) and examined its psychometric properties. These core cognitions were compared among individuals with and without medical conditions.

METHODS

A set of questionnaires that included the CHCQ and the Short Health Anxiety Inventory (SHAI) was used to gather data from 1,319 Chinese college students. After 4 weeks, 145 of the students completed the CHCQ again. The validity, reliability, and measurement invariance were evaluated among individuals with various medical conditions.

RESULTS

The final CHCQ included 19 items. A 4-factor structure was well suited to the data. Good internal consistency (Cronbach's α for total score was 0.849, subscales ranged from 0.753 to 0.841), test-retest reliability (the interclass correlation coefficient for total score was 0.762, subscales ranged from 0.626 to 0.683), and criterion validity of the CHCQ were demonstrated. Measurement and structural invariance were established. Individuals with a diagnosed disease scored higher on the likelihood-of-illness subscale (Cohen's d =0.22, p < 0.01) than those without an illness.

CONCLUSION

The CHCQ shows promise for the assessment of 4 core HA-related cognitions in the Chinese population.

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.

The combination of health anxiety and somatic symptoms: a prospective predictor of healthcare usage in primary care

Extant research provides equivocal conclusions if the combined presentation of health anxiety with severe somatic symptoms confers risk for greater future primary care usage. The present study further examined the combination of health anxiety and somatic symptoms as a predictor of healthcare usage in primary care. Using a prospective longitudinal design, a large sample (N = 530) of patients presenting for treatment at a community health center completed self-report measures assessing health anxiety and somatic symptom severity. A medical record review at the time of questionnaire administration and 1 year following that administration was completed to assess the frequency of medical visits during the preceding and subsequent year. As expected, the interactive effect between health anxiety and somatic symptom severity predicted greater subsequent year medical visits. Covariates included preceding year medical visits, sociodemographic variables, body mass index, smoking status, and depressive symptom severity. Simple effects indicated that health anxiety predicted greater subsequent year medical visits when coupled with relatively severe, but not mild, somatic symptoms. Assessing health anxiety and somatic symptom severity in primary care settings could be important for identifying individuals at risk for future frequent healthcare visits and who may benefit from intervention.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Medically unexplained physical symptoms in patients attending a medical outpatient clinic in a tertiary hospital in North India

OBJECTIVE

Medically unexplained physical symptoms (MUPS) are commonly seen across health care settings. Earlier studies have focussed on prevalence, cost-utilization and burden. Data from India is scarce. Patients with persistent MUPS have more impairment and psychological distress. This study was designed to assess psychological morbidity, health anxiety (HA), somatic symptom load, disability, quality of life (QOL) in patients with persistent MUPS presenting to a general medical outpatient service and compare it with patients with medically explained physical symptoms (MEPS).

METHODS

The study was conducted in the outpatient service of the Department of Internal Medicine in a tertiary hospital in North India. Persistent MUPS was defined as physical symptoms of at least 3 months duration leading to dysfunction and with no identifiable medical cause. 70 patients with persistent MUPS and MEPS each were recruited. Psychiatric morbidity was assessed using the Mini International Neuropsychiatric interview, somatic symptom load with Patient Health Questionniare-15 (PHQ-15), HA with Whiteley Index, disability with WHODAS 2.0 and QOL with WHOQOL-Bref.

RESULTS

Both the groups were comparable on socio-demography and length of symptoms. Prevalence of psychiatric disorders and HA was significantly greater in MUPS. Patients with persistent MUPS had significantly more health care utilization, number and burden of somatic symptoms, greater disability and worse QOL.

CONCLUSIONS

Patients with persistent MUPS have a different profile when compared to MEPS. There is a need to screen and identify patients with MUPS and manage them keeping in mind the psychological factors and chronic nature and number of symptoms.

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.

Measurement invariance across Genders on the Childhood Illness Attitude Scales (CIAS)

OBJECTIVE

The Childhood Illness Attitude Scales (CIAS) were created as a developmentally appropriate measure for symptoms of health anxiety (HA) in school-aged children. Despite overall sound psychometric properties reported in previous studies, more comprehensive examination of the latent structure and potential response bias in the CIAS is needed. The purpose of the present study was to cross-validate the latent structure of the CIAS across genders and to examine gender-specific variations in CIAS scores.

METHODS

The sample comprised data from 602 Canadian and Danish school-aged children (M_age=10.54, SD=0.99; 52.5% girls). Confirmatory factor analyses were conducted to test 3-, modified 3-, and 4-factor models in both samples. Multigroup confirmatory factor analysis was performed to test factor structure invariance across boys and girls in a combined sample. Differential Item Functioning (DIF) was assessed using test characteristic curves.

RESULTS

A modified 3-factor solution (i.e., fears=11 items, help-seeking=6 items, and symptom effects=4 items) provided the best fit to the data (χ² (364, N=602)=681.7, p<0.001; χ²/df=1.803; RMSEA=0.037; CFI=0.926). The factor structure was stable, well-fitting, and indicated measurement invariance across groups. DIF analyses revealed no gender-based response bias at the scale level.

CONCLUSION

Results support a revised 3-factor version of the CIAS that can be used with confidence to assess symptoms of HA in school-aged boys and girls.

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.