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

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.

Efficacy of internet-based psychological interventions for pathological health anxiety: A three-level meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to provide a comprehensive summary and synthesis of available evidence on the efficacy of internet-based psychological interventions for pathological health anxiety, as well as to examine the variables that possibly moderate intervention effects.

METHOD

Four databases were searched for the literature up to October 2023. A three-level random-effects model was used to estimate the pooled effect size, with Hedge's g as the measure.

RESULTS

We extracted 28 effect sizes from nine eligible randomized controlled trials with 1079 participants. The results showed that internet-based psychological interventions had a moderate to large between-group effect on health anxiety (g = 0.70) that was significant both at post-intervention (g = 0.74) and follow-up (g = 0.64). Furthermore, these interventions were significantly more effective than passive control conditions including waitlist, usual care, and placebo at post-treatment (g = 1.07), but had effects comparable to active control groups at both post-intervention and follow-up.

CONCLUSIONS

Internet-based psychological interventions are an effective way to alleviate pathological health anxiety. We recommend that these interventions be more widely implemented in routine care settings to ensure easy accessibility for patients with health anxiety.

Illness anxiety predicts higher mental strain and vaccine willingness-A nine-wave longitudinal study during the first 1.5 years of the COVID-19 pandemic in Germany

Illness anxiety may amplify vulnerability to psychopathological symptoms during the COVID-19-pandemic-perhaps especially at the beginning of the pandemic and during high infection waves, but empirical evidence on this is lacking. In addition, considering a potentially functional facet of it, illness anxiety might be associated with higher vaccine willingness. We analyzed data of a nine-wave longitudinal online-survey (March 2020-October 2021) with 8148 non-probability sampled adults of the general population in Germany (clinicaltrials.gov: NCT04331106). Using multilevel analysis, we investigated longitudinal associations of dimensionally assessed illness anxiety (worry about illness, bodily preoccupation) with mental strain and vaccine willingness and considered the dynamic of the pandemic (i.e., duration and infection rates). Higher worry about illness and bodily preoccupation were associated with higher COVID-19-related fears, unspecific anxiety, depressive symptoms, and vaccine willingness. Vaccine willingness increased over time and in parallel to higher infection rates. Symptoms of mental strain decreased with continuing duration of the pandemic but increased when infection rates inclined. This decrease and increase, respectively, was steeper in individuals with higher illness anxiety. Our findings suggest that individuals with higher illness anxiety are more vulnerable to experience psychopathological symptoms during the ongoing pandemic, particularly at its beginning and during times of high infection rates. Thus, illness anxiety and associated symptoms should be targeted by adaptive measures. The fluctuation of symptoms parallel to the pandemic situation implies that support should be particularly issued at the beginning of extraordinary situations as well as during phases of high infection rates.

Respiratory Interoception and Pathological Illness Anxiety: Disentangling Bias

OBJECTIVE

Biased interoception decoupled from physiology might be relevant in the etiology of pathological illness anxiety (PIA). Empirical evidence for interoceptive deviations in illness anxiety is scarce but potentially informative to optimize treatments. We hypothesized that persons with PIA differ fundamentally in the classification of bodily sensations from those without PIA.

METHODS

In a respiratory categorization task, participants breathed into a pulmonary training device. Inspiration effort was varied by eight resistive loads. The lower/higher four loads were introduced as belonging to arbitrary categories "A"/"B," respectively. Participants memorized respiratory sensations in a first experimental block and were asked to label the resistances in a second block. We calculated the sensitivity of resistance classification according to category and response bias in terms of categorical misclassification. Data of 39 participants with PIA and 35 controls were compared with regard to sensitivity and response bias by group, resistive load, and their interaction in a multiple regression.

RESULTS

With similar sensitivity, patients more often labeled loads above the categorical border erroneously as belonging to category A, thus underestimating their resistance ( β = -0.06, p = .001; η2 = 0.02).

CONCLUSIONS

Individuals with PIA showed a systematic "wait and see" approach. Altered respiroception in PIA might stem from biased perception during training phase, the recognition phase, biased memory, or a combination of these. Its exact characteristics remain unknown, and future research must address the challenge of developing reliable and valid paradigms accounting for the variability of interoceptive biases.

REGISTRATION

This work was preregistered on OSF ( https://osf.io/9shcw ).

COVID-19 pandemic’s impact on networks of depression and anxiety in naturalistic transdiagnostic sample of outpatients with non-psychotic mental illness

Background

The 2019 coronavirus disease (COVID-19) pandemic has caused an unprecedented disruption of daily lives and a mental health crisis. The present study examined how the depression and anxiety symptom network changed during the COVID-19 pandemic in a naturalistic transdiagnostic sample with non-psychotic mental illness.

Materials and methods

A total of 224 psychiatric outpatients before the pandemic and 167 outpatients during the pandemic were included in the study and were assessed for the Patient Health Questionnaire and the Beck Anxiety Inventory. The network of depression and anxiety symptoms before and during the pandemic were estimated separately and were assessed differences.

Results

The network comparison analysis showed a significant structural difference between the networks before and during the pandemic. Before the pandemic, the most central symptom in the network was feelings of worthlessness, while in the during pandemic network, somatic anxiety emerged as the most central node. Somatic anxiety, which showed the highest strength centrality during the pandemic, showed significantly increased correlation with suicidal ideation during the pandemic.

Limitations

The two cross-sectional network analyses of individuals at one point in time cannot demonstrate causal relationships among measured variables and cannot be assumed to generalize to the intraindividual level.

Conclusion

The findings indicate that the pandemic has brought a significant change in the depression and anxiety network and somatic anxiety may serve as a target for psychiatric intervention in the era of the pandemic.

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.