Prevalence and Correlates of Illness Worry in the General Population

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.

Health anxiety and the negative interpretation of children's bodily symptoms in mothers of cancer patients

PURPOSE

Fear of progression (FoP) is a substantial concern for family caregivers of cancer survivors and is related to a number of adverse outcomes, including increased mental distress and worse quality of life. Previous research has revealed that health anxiety (HA) contributes to fear of relapse, but cognitive factors underlying establishing and maintaining FoP in mothers of cancer patients have not been examined. In this study, we were looking to investigate this association.

METHODS

We used the computerized interpretation bias (IB) assessment to investigate the biased interpretation of ambiguous bodily information and its association with FoP through HA among 69 mothers of cancer patients and 42 mothers of healthy kids.

RESULTS

Mothers of cancer patients interpreted more negatively ambiguous bodily symptoms than mothers of healthy kids. Moreover, they had higher levels of HA and FoP and lower quality of life than the healthy group. Also, among mothers of cancer patients, the relationship between negative IB and FoP is mediated by their HA.

CONCLUSIONS

The findings of this study imply that negative IB may contribute to increased HA, which in turn contributes to higher levels of FoP among the mothers of cancer patients, which may reduce the quality of life of their children.

IMPLICATIONS FOR CANCER SURVIVORS

From these findings, we propose that changing HA through modification of IB might lower the FoP in mothers of kids with cancer and improve the mother and child's quality of life.

Examining associations between early adverse life events and health anxiety using the DanFund study

Childhood adverse life events, in particular illness-related events, have been proposed as a risk factor for development of health anxiety.

OBJECTIVE

To examine: 1) The association between accumulated early adverse life events and health anxiety in adulthood and 2) The influence of specific types of life events, i.e., illness, injury, loss, and the impact of their exposure time on health anxiety in adulthood.

METHOD

A population-based, cross-sectional study including 7454 participants from the Danish study of Functional Disorders (DanFunD). Health anxiety was assessed with Whiteley-6-R and early adverse life events with the Cumulative Lifetime Adversity Measure. Caseness was defined as a Whiteley-6-R score ≥ 90%ile. Generalised linear models were used to estimate the association with relative risk (RRa, adjusted for sociodemographics).

RESULTS

A cumulative effect was found for each additional adverse life event with 8.03% increased risk of health anxiety. Two categories were associated with a higher risk: violence (RRa = 1.65, 95% CI: 1.37-1.99, P < 0.001) and relationship stress (RRa = 1.34; 95% CI: 1.15-1.57, P < 0.001). Respondents with self-reported childhood illness were also more likely to report health anxiety (RRa = 1.52, 95% CI 1.11-2.09, P = 0.009). Timewise, health anxiety seemed associated with illness during school age and injury during adolescence.

CONCLUSIONS

Accumulated adverse life events, early exposure to specific categories and specific health-related life events were associated with self-reported health anxiety in adulthood. Our findings provide new knowledge on the potential role of early life events in health anxiety which could inform early intervention.

Somatic Symptom Disorder and Health Anxiety: Assessment and Management

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD) replaced the diagnostic entities of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) somatoform disorders and hypochondriasis. SSD turns away from specifying the presence or absence of a medical condition for presented symptoms and instead focuses on excessive symptom-related affects, cognitions, and behaviors. People with pathological health anxiety can be diagnosed with SSD or IAD, depending on the intensity of accompanying somatic symptoms. Cognitive-behavioral therapy shows the best empirical evidence for an effective treatment of SSD and IAD.

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.

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.

Social inequalities in health anxiety: A systematic review and meta-analysis

OBJECTIVE

The association between a low socioeconomic status and poor health, also known as social inequalities in health, has been shown in numerous studies. This also applies to most mental illnesses, such as somatization or anxiety disorders. It is unclear, however, whether social inequalities are evident in health anxiety as well. Therefore, this review and meta-analysis systematically examines social inequalities in health anxiety.

METHODS

A systematic literature search was conducted covering all studies published until August 2021. The databases PubMED, Web of Science, PsycINFO, and PSYNDEX were screened to identify quantitative studies using validated tools to measure health anxiety and examining the association with socioeconomic status. Meta-analytic methods were applied by using random-effect models. The study quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool.

RESULTS

Overall, 37 studies were eligible for meta-analysis. Effect sizes of 27 studies using screening scales and 10 studies using diagnostic interviews to measure health anxiety were calculated separately. Meta-analyses revealed a significant association between socioeconomic status and health anxiety (r - 0.14, 95%-CI -0.18 to -0.09 (screening scales) and OR 0.63, 95%-CI 0.43 to 0.92 (diagnostic interviews)), indicating a lower risk for health anxiety in people with higher socioeconomic status.

CONCLUSION

Findings suggest that the health-related disadvantage of socially deprived people is also evident regarding health anxiety. This should be considered in programs to reduce social inequalities in health. PROSPERO registration number CRD42021237550.

Predictors of health anxiety in cancer patients' loved ones: A controlled comparison

OBJECTIVE

Cognitive-behavioural models suggest that vicarious illness experiences precipitate health anxiety; however, this assumption is largely untested. This study aimed to (a) compare the severity of health anxiety and rates of clinical health anxiety, Illness Anxiety Disorder (IAD), and Somatic Symptom Disorder (SSD) in participants with and without a loved one with cancer, and (b) determine the predictors of health anxiety severity in participants with vicarious cancer experiences.

METHODS

Participants with (n = 142) and without (n = 65) vicarious cancer experiences completed an online battery of questionnaires assessing the severity and cognitive, physiological, and behavioural components of health anxiety. Participants reporting clinical levels of health anxiety completed a diagnostic telephone interview to assess for IAD and SSD.

RESULTS

Severity and rates of clinical health anxiety, IAD, and SSD did not differ between groups. Participants with a vicarious experience of cancer reported elevated fear of cancer recurrence regarding their loved one's illness, however only 15.8% reported clinically significant health anxiety. Hierarchical regression revealed that in participants with vicarious cancer experiences, less relationship closeness and greater perceived risk of cancer, severity of somatic symptoms, bodily hypervigilance, and catastrophic interpretation of symptoms predicted health anxiety. Being a caregiver for or genetically related to the person with cancer, the expectedness of the cancer diagnosis, and whether the loved one died from cancer were not significant predictors.

CONCLUSIONS

These results suggest that people reporting vicarious cancer experiences do not have elevated rates of health anxiety. However, how these individuals interpret their experiences influences health anxiety severity.

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.

Illness Anxiety Disorder: Psychopathology, Epidemiology, Clinical Characteristics, and Treatment

Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms. An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collaboration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.

Effects of maternal health anxiety on children's health complaints, emotional symptoms, and quality of life

Little is known about family risk factors and intergenerational transmission of psychological disturbance in the development of health anxiety (HA). This study investigated HA and related concepts in 8- to 17-year-old children who had been exposed to different maternal health status. Using a family case-control design, three family groups were included: (1) 50 case children of mothers with severe (HA); (2) 49 control children of mothers with rheumatoid arthritis (RA); and (3) 51 control children of healthy mothers. Children and mothers completed a battery of standardised questionnaires. Case children reported significantly higher level of HA symptoms than children of mothers with RA but not compared to children of healthy mothers. There was no significant difference between the children's self-reports in the three groups with regard to anxiety symptoms in general, physical complaints, or quality of life. In contrast, mothers with HA reported their children as having more emotional and physical symptoms than mothers in one or both control groups. Compared to mothers with RA but not healthy mothers, mothers with HA also reported more visits to the general practitioner with their children during the past year. The findings suggest that maternal HA only weakly affects children's own report of HA and thereby may not be a strong risk factor for the development of HA symptoms in childhood. However, mothers with severe HA seem to conceive their children as more ill and present them more often in the health care system which could, therefore, be an important target for intervention in adult patients.

Health anxiety symptoms in children and adolescents diagnosed with OCD

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

Health anxiety and risk of ischaemic heart disease: a prospective cohort study linking the Hordaland Health Study (HUSK) with the Cardiovascular Diseases in Norway (CVDNOR) project

BACKGROUND

The risk of ischaemic heart disease (IHD) is largely influenced by lifestyle. Interestingly, cohort studies show that anxiety in general is associated with increased risk of IHD, independent of established risk factors for cardiovascular disease. Health anxiety is a specific type of anxiety characterised by preoccupation of having, acquiring or possibly avoiding illness, yet little is known about lifestyle and risk of disease development in this group.

AIM

Investigate whether health anxiety is prospectively associated with IHD, and whether a potential association can be explained by the presence or absence of established risk factors for cardiovascular diseases.

METHODS

Incident IHD was studied among 7052 participants in the community-based Hordaland Health Study (HUSK) during 12 years follow-up by linkage to the Cardiovascular Diseases in Norway (CVDNOR) project. Scores above 90th centile of the Whiteley Index defined health anxiety cases. Associations were examined with the Cox proportional regression models.

RESULTS

During follow-up, 6.1% of health anxiety cases developed IHD compared with 3.0% of non-cases, yielding a gender-adjusted HR of 2.12 (95% CI 1.52 to 2.95). After adjustments for established cardiovascular risk factors, about 70% increased risk of IHD was found among cases with health anxiety (HR: 1.73 (95% CI 1.21 to 2.48)). The association followed a dose-response pattern.

CONCLUSIONS

This finding corroborates and extends the understanding of anxiety in various forms as a risk factor for IHD. New evidence of negative consequences over time underlines the importance of proper diagnosis and treatment for health anxiety.

Panic attacks and smoking cessation among cancer patients receiving smoking cessation treatment

OBJECTIVE

Little is known about factors associated with smoking cessation in cancer patients. This study examined the impact of panic attacks on smoking abstinence likelihood among cancer patients receiving tobacco cessation treatment.

METHOD

The relationship of panic attacks to 7-day point-prevalence abstinence at mid-treatment, end of treatment, and 6-month post-end of treatment were examined among cancer patients (N=2255 patients; 50.1% female; Mage=54.9, SD=11.0) who received counseling and pharmacotherapy for smoking cessation. Panic attack history indexed by two questions from the Patient Health Questionnaire (PHQ). Point-prevalence abstinence was assessed via the Timeline Follow-Back.

RESULTS

Cancer patients with a history of panic attacks, (n=493, 21.9%) relative to those without, were less likely to be abstinent at mid-treatment (OR=0.79, CI95%=0.64-0.98) and end of treatment (OR=0.72, CI95%=0.58-0.89). After adjusting for significant covariates, panic attack history remained predictive of decreased abstinence likelihood at end of treatment (OR =0.78, CI95%=0.62-0.99).

CONCLUSIONS

Panic attacks may be related to poorer cessation outcome during smoking treatment among cancer patients, and may be usefully assessed and targeted for intervention.

The prospective association between health anxiety and cancer detection: A cohort study linking the Hordaland Health Study (HUSK) with the Norwegian Cancer Registry

OBJECTIVE

Health anxiety is associated with distress and disability, and overutilization of health services, but it is not known whether high levels of health anxiety may lead to increased detection of severe diseases such as cancer. By linking a large population based health study with the national cancer registry, the aim of the study was to investigate a potential prospective association between health anxiety in men and women and later cancer detection and tumour metastasis at the time of diagnosis.

METHOD

A longitudinal study with a 13.2 year follow-up linking the population-based Hordaland Health Study (HUSK) and the Cancer Registry of Norway (CRN) was conducted. Health anxiety was measured with the Whiteley Index. Associations were examined through gender stratified Cox regression analyses adjusted for relevant covariates.

RESULTS

No association was found between baseline health anxiety and cancer detection for women (adjusted HR: 1.21, 95% CI: 0.42-3.50), but a positive association was found between health anxiety at baseline and cancer detection for men (adjusted HR: 1.76, 95% CI: 1.06-2.91). No statistically significant association was demonstrated between health anxiety and cancer metastasis for either gender.

CONCLUSION

An increased level of health anxiety in men may be advantageous, as it may motivate to self-examination and healthcare seeking when disturbing symptoms arise. Research is needed to investigate whether health anxiety has a protective effect on cancer metastasis at the time of detection, or whether health anxiety increases the risk of over-diagnosis and overtreatment.

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

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

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

BACKGROUND

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

AIMS

Our study tested this central tenet of the CB model.

METHOD

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

RESULTS

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

CONCLUSIONS

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

Adverse effects of health anxiety on management of a patient with benign paroxysmal positional vertigo, vestibular migraine and chronic subjective dizziness

INTRODUCTION

Care of patients with vestibular symptoms focuses primarily on physical otoneurologic disorders; however, psychological factors can sustain symptoms, confound assessment, and adversely affect treatment. Health anxiety is a particularly pernicious process that simultaneously magnifies physical symptoms and inhibits medical care.

OBJECTIVE

To demonstrate the excess morbidity caused by vestibular health anxiety and its successful management in a patient with otoneurologic disease.

METHOD

Report of a 41-year-old woman with recurrent benign paroxysmal positional vertigo, vestibular migraine, and chronic subjective dizziness, who expressed grave concerns about her health, repeatedly questioned her otoneurologic diagnoses, and failed physical therapy and medication treatment until her health anxiety and otoneurologic illnesses were addressed simultaneously.

CONCLUSION

Health anxiety is an empirically validated concept that explains troublesome health-related beliefs and behaviors. It is frustrating for patients and health care teams, but can be treated successfully in otoneurology practice, thereby reducing physical symptoms, emotional distress, functional impairment, and health care overutilization.

Associations between risk perceptions and worry about common diseases: a between- and within-subjects examination

The relationships between worry and perceptions of likelihood and severity were evaluated across eight common diseases. Individual and disease variability in worry and perceptions were examined. 294 participants were recruited through the Multiplex Initiative, in which a genetic susceptibility test for eight common diseases was offered to healthy adults. Participants completed a baseline telephone survey and web-based surveys without a commitment to be tested, and then made a choice on testing. Between- and within-subjects analyses yielded the following main findings: (1) worry is more closely related to likelihood perceptions than to severity perceptions; (2) severity perceptions add significantly to explained worry variances above and beyond likelihood perceptions; (3) risk perceptions and worries form two clusters: cancer diseases and cardiovascular-metabolic diseases; and (4) variance in risk perception and worry is explained by a combination of between- and within-subjects variances. Risk perception research should attend to severity perceptions, within-subjects variability and inter-disease differences, and to strategies for grouping conditions.

Modelling decisions to undergo genetic testing for susceptibility to common health conditions: an ancillary study of the Multiplex Initiative

New genetic tests reveal risks for multiple conditions simultaneously, although little is understood about the psychological factors that affect testing uptake. We assessed a conceptual model called the multiplex genetic testing model (MGTM) using structural equation modelling. The MGTM delineates worry, perceived severity, perceived risk, response efficacy and attitudes towards testing as predictors of intentions and behaviour. Participants were 270 healthy insured adults aged 25-40 from the Multiplex Initiative conducted within a health care system in Detroit, MI, USA. Participants were offered a genetic test that assessed risk for eight common health conditions. Confirmatory factor analysis revealed that worry, perceived risk and severity clustered into two disease domains: cancer or metabolic conditions. Only perceived severity of metabolic conditions was correlated with general response efficacy (β = 0.13, p<0.05), which predicted general attitudes towards testing (β = 0.24, p<0.01). Consistent with our hypothesised model, attitudes towards testing were the strongest predictors of intentions to undergo testing (β = 0.49, p<0.01), which in turn predicted testing uptake (OR 17.7, β = 0.97, p<0.01). The MGTM explained a striking 48% of the variance in intentions and 94% of the variation in uptake. These findings support use of the MGTM to explain psychological predictors of testing for multiple health conditions.

Hypochondrische Merkmale bei Patienten einer psychotherapeutischen Ambulanz

Zusammenfassung. Theoretischer Hintergrund: Während die Hypochondrie eine relativ niedrige Prävalenz aufweist, gibt es Hinweise, dass hypochondrische Merkmale unterhalb der diagnostischen Schwelle deutlich häufiger vorliegen. Fragestellung: Wie häufig bestehen bei ambulanten Psychotherapiepatienten ausgeprägte hypochondrische Merkmale? Kann die hypochondrische Symptomatik durch bestehende somatische Krankheiten erklärt werden? Welche Risikofaktoren könnten bedeutsam sein? Methode: 85 Patienten einer psychotherapeutischen Ambulanz wurden hinsichtlich des Vorliegens hypochondrischer Merkmale, Krankheitserfahrungen und traumatischer Erfahrungen in der Kindheit untersucht. Ergebnisse: Je nach Cut-off-Kriterium zeigten sich bei 24–34% der Patienten ausgeprägte krankheitsbezogene Befürchtungen, die in geringem Umfang (6–10%) durch einen schlechteren Gesundheitsstatus erklärt werden konnten. Potenziell relevant für hypochondrische Symptome zeigte sich zudem die Anzahl verstorbener Familienangehöriger. Schlussfolgerung: Hypochondrische Merkmale sollten in der ambulanten psychotherapeutischen Versorgung eine größere Beachtung finden, da sie von den Patienten häufig berichtet werden.

Health anxiety among older people: an exploratory study of health anxiety and safety behaviors in a cohort of older adults in New Zealand

BACKGROUND

Despite a stereotype that characterizes older people as excessively anxious about their health, there is little research into this phenomenon. The present exploratory study examined: (a) whether a cohort of older adults was unduly health anxious, (b) which demographic and health factors predicted health anxiety (HA), and (c) whether an aspect of the cognitive behavioral model of HA was applicable to older adults by investigating the relationship between HA and safety behaviors.

METHOD

Participants were a convenience sample of adults aged over 65 and living independently in Auckland, New Zealand. Participants (104 women and 41 men) completed an anonymous self-report questionnaire measuring demographic factors, physical health and function, health anxiety, safety behaviors, and medical utilization.

RESULTS

This cohort of adults over 65 were not unduly health anxious. Occurrence of severe HA was similar to that found in younger populations. Decreased physical function and lower education predicted scores on the HA measure. Consistent with the cognitive behavioral model, HA was a unique significant predictor of safety behaviors. HA and decreased physical function predicted medical utilization.

CONCLUSIONS

Generally low levels of HA among this cohort of older individuals challenged the pervasive stereotype of the "hypochondriacal" older person. Factors contributing to HA were similar to those reported in studies with younger cohorts. Findings provided preliminary support for the applicability of the cognitive behavioral model of HA to adults over 65. Implications of the findings and directions for future research were discussed.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

What impact does pregnancy have on anxiety about health?

BACKGROUND

A previous study suggests that health anxiety, or preoccupation and fears about ill health, is elevated during pregnancy. However, replication of this result is needed given several methodological weaknesses of the previous research. The current study refined earlier work by assessing health anxiety using two distinct measures and comparing scores to a control group and to established norms for healthy controls. The relationship of health anxiety to background variables such as parity and pregnancy complications was also explored.

METHODS

A total of 252 women in the third trimester of pregnancy and 45 similarly aged non-pregnant women completed the Illness Attitudes Scale (IAS) and the newly developed Short Health Anxiety Inventory (SHAI).

RESULTS

Compared to the non-pregnant sample and established scores for healthy controls, health anxiety was not elevated during pregnancy. Health anxiety was higher in women who experienced complications during pregnancy but was unrelated to other background variables. The IAS identified more individuals as health anxious than the SHAI.

CONCLUSIONS

Contrary to previous research, health anxiety was not elevated during pregnancy. The IAS appeared to be susceptible to identifying women as health anxious due to greater health care utilization by pregnant women rather than higher health anxiety. Clinical recommendations and future directions for the assessment of health anxiety are outlined.

Illness behavior in patients on long-term sick leave due to chronic musculoskeletal pain

BACKGROUND AND PURPOSE

Methods for identification of patients with illness behavior in orthopedic settings are still being debated. The purpose of this study was to test the association between illness behavior, depressed mood, pain intensity, self-rated disability, and clinical status in patients with chronic musculoskeletal pain (CMP).

METHODS

We examined 174 consecutive sick-listed patients (90 women). Musculoskeletal function was estimated by range of motion, muscle strength, and motor and sensory function. The degree of illness behavior was measured by Waddell signs (WS), RESULTS: WS were observed in 47/174 (27%) of the patients, 16% of whom manifested excessive illness behaviour. In general, more patients with WS were depressed (OR = 4.4; 95% CI: 1.8-11) and experienced greater pain (OR = 2.9; CI: 1.1-7.7). No abnormal physical function could be observed in two-thirds of the patients. Other predictive factors for manifesting WS at the clinical examinations were longer sick leave and previous full sick leave (p < 0.05).

INTERPRETATION

Excessive illness behavior is related to psychological distress in patients with CMP and long-term disability. Thus, some patients may also require psychological assessment. Looking for WS during consultation is useful for targeting other factors that may be important in the diagnostic process.

A taxometric analysis of health anxiety

BACKGROUND

A long-standing issue in the health anxiety literature is the extent to which health anxiety is a dimensional or a categorical construct. This study explores this question directly using taxometric procedures.

METHOD

Seven hundred and eleven working adults completed an index of health anxiety [the Whiteley Index (WI)] and indicated their current health status. Data from those who were currently healthy (n=501) and receiving no medical treatment were examined using three taxometric procedures: mean above minus below a cut (MAMBAC), maximum eigenvalue (MAXEIGEN) and L-mode factor analysis (L-MODE).

RESULTS

Graphical representations (comparing actual to simulated data) and fit indices indicate that health anxiety is more accurately represented as a dimensional rather than a categorical construct.

CONCLUSIONS

Health anxiety is better represented as a dimensional construct. Implications for theory development and clinical practice are examined.

Advances in understanding illness anxiety

Illness anxiety, also known in its more severe form as hypochondriasis, is a debilitating and chronic condition in which normal bodily symptoms are misinterpreted as signs of serious medical illness. Patients suffer with the fear that they are ill despite reassurance to the contrary and often overuse medical services in the process. This article critically evaluates the recent literature on illness anxiety and related, medically unexplained symptoms, highlighting new and interesting findings in the areas of prevalence, classification/diagnosis, management, and evidence-based treatment and new frontiers in understanding illness anxiety, such as brain imaging, neuroimmunology, and cyberchondria.

Trauma experience in individuals with idiopathic environmental intolerance and individuals with somatoform disorders

OBJECTIVE

Results from previous studies suggest that past trauma experience increases the risk for medically unexplained somatic symptoms and somatoform disorders (SFD). This cross-sectional study examined the link between various lifetime traumas, idiopathic environmental intolerance (IEI), and SFD.

METHODS

Two clinical groups of 54 subjects with IEI and 44 subjects with SFD were compared to 54 subjects (comparison group, CG) free from both IEI and SFD regarding self-reported traumas. The subjects were mainly recruited via advertisements in local newspapers. From 970 individuals screened for IEI and multiple somatic symptoms, 152 were included through a two-step selection procedure consisting of screening questionnaires, a medical examination, and structured interviews for IEI and mental disorders.

RESULTS

In all three groups at least one potential traumatic event was reported rather frequently (CG: 70%; IEI: 82%; SFD: 73%). But contrary to our expectation, significant group differences were neither found in regard to the proportion of subjects with any trauma, nor traumas fulfilling DSM-IV criteria (CG: 41%; IEI: 48%; SFD: 59%), nor multiple traumas (CG: 43%, IEI: 56%, SFD: 39%). Only two trauma categories were endorsed more frequently by the two clinical groups than by the CG: the unspecified 'other' category (IEI, SFD>CG) and 'life-threatening illness' (IEI>CG).

CONCLUSION

No clear evidence was found for increased rates of trauma experience in IEI and SFD. However, the results of this exploratory study should be considered as preliminary. Comparing larger IEI and SFD groups with a representative population-based sample may yield different results.

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.

Körperbeschwerden und Gesundheitsangst in der Primärmedizin

Zusammenfassung. Patienten mit erhöhter Gesundheitsangst verursachen erhebliche Kosten für das Gesundheitssystem. Die durchgeführten medizinischen Untersuchungen und Behandlungen sind häufig unangemessen, denn in etwa der Hälfte der Fälle liegt den Krankheitsbefürchtungen keine organische Erkrankung zugrunde. Im Rahmen der kontrollierten cluster-randomisierten Studie FUNKTIONAL wurden in 29 Hausarztpraxen bei 1751 Patienten systematisch Gesundheitsangst (Whiteley-7), körperliche und psychische Symptome (PHQ-D) sowie die ärztliche Einschätzung des Hausarztes erfasst. Es fand sich eine verstärkte psychische und globale Funktionsbeeinträchtigung bei Patienten mit erhöhter Gesundheitsangst, die auf Patient- und Arztseite angegeben wird. Psychosoziale Faktoren werden vom Behandler häufiger als für die Erkrankung relevant betrachtet, wenn Patienten erhöhte Gesundheitsangst zeigen. Die Erkennung und Reduktion von Gesundheitsangst in der Allgemeinarztpraxis stellt sich also als relevanter Behandlungsaspekt dar, auch wenn keine hypochondrische Erkrankung im engeren Sinne vorliegt.

Features of hypochondriasis and illness worry in the general population in Germany

OBJECTIVE

Although hypochondriasis is considered to be of high relevance in the healthcare sector, its prevalence in the general population has been investigated in few studies. The aims of this study were to estimate prevalence rates of hypochondriasis and of subthreshold conditions and to describe their associated features such as quality of life and healthcare utilization in a representative community sample.

METHODS

Analyses of the present study are based on the German Health Interview and Examination Survey-Mental Health Supplement (N = 4181, representative for the German population from 18-65 years). The assessment included interviews for somatic conditions and mental disorders and self-report ratings on health-related quality of life, healthcare utilization, disability days, and physical activity.

RESULTS

Only three cases (0.05%) were identified as meeting full criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) hypochondriasis. The prevalence rate of the less restrictively defined form of hypochondriasis, ("subthreshold hypochondriasis") was 0.58% and an additional 2.12% reported having had illness worries for at least 6 months but did not meet further hypochondriasis criteria. The two subthreshold diagnostic groups provided strong evidence of difference from the nonhypochondriac controls: comorbidity with psychiatric and medical disorders and healthcare utilization were higher, and quality of life was markedly reduced.

CONCLUSIONS

The results provide additional support to not only consider "full" DSM-IV hypochondriasis, which is a very rare disorder in the general population, but also to include less restrictive hypochondriac conditions--associated with a clinically relevant degree of psychological and physical impairment--into clinical and scientific considerations.