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

Effectiveness and prediction of treatment adherence to guided internet-based cognitive behavioral therapy for health anxiety: A cohort study in routine psychiatric care

Objective

Health anxiety, also known as hypochondriasis, is a common psychiatric disorder which leads to considerable distress and is associated with high societal costs. Internet-based cognitive behavioural therapy (ICBT) for health anxiety has demonstrated efficacy in randomized controlled trials (RCTs), but there is limited knowledge regarding its effectiveness in real-world settings. This study aimed to evaluate the clinical effectiveness of guided ICBT for health anxiety in routine psychiatric care, including symptom change, treatment adherence, and potential negative effects. Additionally, we explored predictors of treatment adherence.

Method

A longitudinal cohort study of 447 patients enrolled in 12 weeks of ICBT for health anxiety between 2018 and 2020 in an outpatient psychiatric clinic specializing in ICBT. Primary outcome measure was the 14-item Short Health Anxiety Inventory (SHAI-14) and a within-group design with repeated measures was utilized for the primary analysis.

Results

Participants showed significant improvements from pre- to post-treatment (d = 1.61). At post-treatment, 60 % (95 % CI 58-62) demonstrated statistically reliable change (RCI), and 44 % (95 % CI 42-46) were in remission. On average, participants completed 7 (SD = 4) out of 12 treatment modules. For each additional completed module, the mean reduction was 0.31 (95 % CI 0.10 to 0.54) points on the SHAI-14.

Conclusions

Guided ICBT for health anxiety can be effective when delivered within the context of routine psychiatric care. The study suggests that effect sizes are comparable with those in RCTs and higher treatment adherence is associated with better outcomes in health anxiety. ICBT could be used to increase availability to effective therapy for health anxiety.

Development and psychometric properties of the Health Anxiety Behavior Inventory (HABI)

BACKGROUND

Mainstream cognitive behavioural theory stipulates that clinically significant health anxiety persists over time at least partially due to negatively reinforced health-related behaviours, but there exists no broad and psychometrically valid measure of such behaviours.

AIMS

To draft and evaluate a new self-report scale - the Health Anxiety Behavior Inventory (HABI) - for the measurement of negatively reinforced health anxiety behaviours.

METHOD

We drafted the HABI from a pool of 20 candidate items administered in a clinical trial at screening, and before and after cognitive behaviour therapy (n=204). A psychometric evaluation focused on factor structure, internal consistency, convergent and discriminant validity, test-retest reliability, and sensitivity to change.

RESULTS

Based on factor analysis, the HABI was completed as a 12-item instrument with a four-dimensional factor structure corresponding to the following scales: (i) bodily preoccupation and checking, (ii) information- and reassurance-seeking, (iii) prevention and planning, and (iv) overt avoidance. Factor inter-correlations were modest. The internal consistency (α=.73-.87) and 2-week test-retest reliability (r=.75-.90) of the scales was adequate. The bodily preoccupation and checking, and information- and reassurance-seeking scales were most strongly correlated with the cognitive and emotional components of health anxiety (r=0.41, 0.48), and to a lower extent correlated to depressive symptoms and disability. Change scores in all HABI scales correlated with improvement in the cognitive and emotional components of health anxiety during cognitive behaviour therapy.

CONCLUSIONS

The HABI appears to reliably measure negatively reinforced behaviours commonly seen in clinically significant health anxiety, and might be clinically useful in the treatment of health anxiety.

Brief digital self-care intervention for health anxiety in a Swedish Medical University Clinic: a prospective single-group feasibility study

OBJECTIVES

In routine psychiatric care in Stockholm, Sweden, a comprehensive therapist-guided intervention for clinically significant health anxiety is implemented. However, there is a need for more easily accessible self-care interventions to improve treatment dissemination. This study aimed to transform an existing therapist-guided digital intervention into a self-care intervention, reducing patient burden and used clinical resources while maintaining quality and safety.

DESIGN

An uncontrolled feasibility study.

SETTING

Conducted at Karolinska Institutet, a medical university in Sweden, with nationwide recruitment trough online advertisements.

PARTICIPANTS

Twenty-five adults used the self-care intervention and underwent telephone assessments, along with completing self-rated questionnaires.

INTERVENTION

The newly developed 8-week self-care intervention was designed to be user-friendly without therapist guidance, and to facilitate high levels of behavioural engagement.

PRIMARY AND SECONDARY OUTCOME MEASURES

Indicators of quality and safety, including changes in health anxiety severity (primary), clinician time, participant adherence, perceived credibility/satisfaction with the intervention and adverse events, were benchmarked against a previous study of the more comprehensive intervention it was based on.

RESULTS

Compared with the original guided intervention, the self-care intervention was condensed in terms of text (up to 70% less reading), duration (8 weeks instead of 12) and number of exercises. Quality indicators were similar to the original version. Most participants worked actively with core components in the self-care intervention. Within-group effects on health anxiety from pretreatment to the 3-month follow-up were large (g=1.37; 95% CI 0.74 to 2.00). No serious adverse events were reported.

CONCLUSIONS

This brief digital self-care intervention shows potential for increasing access to treatment for individuals with health anxiety while reducing the burden on patients and clinical resources. Future studies should investigate the optimal type of intervention and support for different individuals, and if non-inferiority can be established.

TRIAL REGISTRATION NUMBER

NCT05446766.

Death Preparedness: Development and Initial Validation of the Advance Planning Preparedness Scale

Delayed advance planning and costs of life sustaining treatments at end of life significantly contribute to the economic burden of healthcare. Clinician barriers include perceptions of inappropriate timing, lack of skills in end-of-life communication and viewing readiness as a behavior rather than a death attitude. This study developed and validated a measurement of psychological preparedness for advance directive completion. Confirmatory factor analysis (N = 543) of a 35 item pool (Cronbach α = .96) supported five sub-scales; psychological comfort (α = .87), desire to know (α = .88), thinking (α = .84), willingness (α = .82) and existential reflection (α = .79) with a possible common factor (α = .84). Results suggested significant predictors of completing directives in 30 days included discussion (OR .08, p < .001), preparedness (OR 4.08, p = .03) and uncertainty (OR 4.37, p = .02). APP = 35 is a reliable and valid measure with utility to assess readiness for completion of EOL documents.

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.

Unwanted outcomes in cognitive behavior therapy for pathological health anxiety: a systematic review and a secondary original study of two randomized controlled trials

INTRODUCTION

Cognitive behavior therapy (CBT) is effective for pathological health anxiety, but little is known about unwanted outcomes.

AREAS COVERED

We investigated unwanted outcomes in the form of adverse events, overall symptom deterioration, and dropouts in CBT for pathological health anxiety based on a systematic review of 19 randomized controlled trials (PubMed, PsycInfo, and OATD; last updated 2 June 2023; pooled N = 2188), and then a secondary original study of two randomized controlled trials (pooled N = 336). In the systematic review, 10% of participants in CBT reported at least one adverse event and 17% dropped out. Heterogeneity was substantial. In the original investigation, 17% reported at least one adverse event, 0-10% met criteria for overall symptom deterioration, and 10-19% dropped out. In guided Internet-delivered CBT, dropouts were more common with lower education and lower credibility/expectancy ratings. Higher adherence was associated with a larger reduction in health anxiety.

EXPERT OPINION

Unwanted effects are routinely seen in CBT for pathological health anxiety, but, under typical circumstances, appear to be acceptable in light of the treatment's efficacy. There is a need for more consistent methods to improve our understanding adverse events, dropouts, and overall symptom deterioration, and how these outcomes can be prevented.