An experimental analysis of hypochondriasis

Hypochondriasis (HC) involves preoccupation with fears of having a serious medical illness based on the misinterpretation of benign bodily perturbations. Individuals with HC also perform behaviors such as checking and reassurance-seeking presumably to reduce health-related fears. Experimental behavioral analyses of HC symptoms, however, are lacking. In the present study, 27 patients with HC were exposed to personally relevant health-related stimuli under one of two conditions: (a) subsequently performing safety-seeking behaviors (e.g., checking) (n=14) or (b) subsequently being instructed not to perform such behaviors (n=13). In both groups, subjective anxiety and urges to perform safety behaviors were monitored for 1h. Results indicated that exposure to the personally relevant health trigger provoked anxiety and urges to perform safety behaviors. For patients who performed such behaviors, these feelings were reduced. For patients who did not, a more gradual reduction of anxiety and urges was observed. Findings are discussed in terms of the conceptualization and treatment of HC behavior, and are relevant to HC's possible relationship to panic and obsessive-compulsive disorder.     

A taxometric study of hypochondriasis symptoms

Hypochondriasis has been conceptualized as both a distinct category that is characterized by a disabling illness preoccupation and as a continuum of health concerns. Empirical support for one of these theoretical models will clarify inconsistent assessment approaches and study designs that have impeded theory and research. To facilitate progress, taxometric analyses were conducted to determine whether hypochondriasis is best understood as a discrete category, consistent with the DSM, or as a dimensional entity, consistent with prevailing opinion and most self-report measures. Data from a large undergraduate sample that completed 3 hypochondriasis symptom measures were factor analyzed. The 4 factor analytically derived symptom indicators were then used in these taxometric analyses. Consistent with our hypotheses and existing theory, results supported a dimensional structure for hypochondriasis. Implications for the conceptualization of hypochondriasis and directions for future study are discussed.     

Health anxiety, hypochondriasis, and the anxiety disorders

Although clinical observations suggest that health-related anxiety is present, to some extent, in a number of anxiety disorders, this relationship has not been examined empirically. The present study therefore utilized the Short Health Anxiety Inventory (SHAI) to elucidate the structure of such symptoms among patients with anxiety disorders and to empirically investigate the presence of health anxiety in various anxiety disorders. Confirmatory factor analysis yielded equivalent support for either a 2-factor or 3-factor model of the SHAI's latent structure. The measure demonstrated good reliability, convergent validity, and discriminant validity. Comparison of SHAI scores across groups of patients with various anxiety disorders revealed elevated levels of health anxiety among patients with hypochondriasis and panic disorder relative to those with other anxiety disorders. Receiver operating characteristic analyses supported the utility of the SHAI as a diagnostic tool for screening patients with hypochondriasis utilizing empirically derived cut scores. Findings are discussed in terms of cognitive-behavioral models of anxiety disorders.     

Automatization and training in visual search.

In several search tasks, the amount of practice on particular combinations of targets and distractors was equated in varied-mapping (VM) and consistent-mapping (CM) conditions. The results indicate the importance of distinguishing between memory and visual search tasks, and implicate a number of factors that play important roles in visual search and its learning. Visual search was studied in Experiment 1. VM and CM performance were almost equal, and slope reductions occurred during practice for both, suggesting the learning of efficient attentive search based on features, and no important role for automatic attention attraction. However, positive transfer effects occurred when previous CM targets were re-paired with previous CM distractors, even though these targets and distractors had not been trained together. Also, the introduction of a demanding simultaneous task produced advantages of CM over VM. These latter two results demonstrated the operation of automatic attention attraction. Visual search was further studied in Experiment 2, using novel characters for which feature overlap and similarity were controlled. The design and many of the findings paralleled Experiment 1. In addition, enormous search improvement was seen over 35 sessions of training, suggesting the operation of perceptual unitization for the novel characters. Experiment 3 showed a large, persistent advantage for CM over VM performance in memory search, even when practice on particular combinations of targets and distractors was equated in the two training conditions. A multifactor theory of automatization and attention is put forth to account for these findings and others in the literature.     

Interpretation of bodily symptoms in hypochondriasis.

Although it has been suggested that hypochondriasis is caused by the misinterpretation of innocuous bodily sensations, support for this hypothesis rests largely upon uncontrolled self-report. We investigated the interpretation of ambiguous bodily sensations in three experiments using separate samples of non-clinical subjects differing in level of hypochondriacal concern. Results confirmed that subjects with high hypochondriacal concern endorse more thoughts about illness interpretations of bodily sensations, but reported thought content resembled 'catastrophic' rather than the 'non-emergency' thoughts suggested by Warwick and Salkovskis (Hypochondriasis. Behavior Research and Therapy, 28, 105-117, 1990). Presence of an interpretive bias was further supported in a study of recognition bias for disambiguated versions of ambiguously threatening sentences, although this applied as much to social as to illness threats. A final experiment failed to support the hypothesis of an automatic inference bias, but did show that subjects with high hypochondriacal concern were quicker to correctly identify previously exposed illness words. Thus, reported thoughts are consistent with catastrophic interpretations of common bodily sensations, but interpretive bias may not be limited to illness threat. However, high hypochondriacal subjects do show a more specific enhanced perceptual sensitivity to illness cues, which may play a role in maintaining their concern with bodily symptoms.     

The role of disgust in patients with hypochondriasis

Theoretically, disgust sensitivity and disgust proneness could play an important role in hypochondriasis, since disgust is a defensive emotion widely believed to protect the organism from illness. However, empirical evidence to support this hypothesis has so far been based only on nonclinical samples, so that the importance and specificity of disgust for hypochondriasis remains unclear. In the current study, 36 patients with hypochondriasis, 27 with an anxiety disorder, and 29 healthy controls completed several measures which included the assessment of disgust sensitivity (Scale for the Assessment of Disgust Sensitivity) and disgust proneness (Questionnaire for the Assessment of Disgust Proneness). We found that patients with hypochondriasis and those with an anxiety disorder had higher scores than those of the healthy controls for several measures of disgust proneness. Moreover, measures of hypochondriacal characteristics were associated with those of disgust proneness and disgust sensitivity. However, no differences were found between patients with hypochondriasis and those with anxiety disorders, with respect to disgust proneness and disgust sensitivity. Therefore, it can be assumed that disgust proneness and disgust sensitivity seem to be less specific than previously suggested for the development and maintenance of hypochondriasis.     

Health anxiety and hypochondriasis in the light of DSM-5

Background: In the DSM-5, the diagnosis of hypochondriasis was replaced by two new diagnositic entities: somatic symptom disorder (SSD) and illness anxiety disorder (IAD). Both diagnoses share high health anxiety as a common criterion, but additonal somatic symptoms are only required for SSD but not IAD. Design: Our aim was to provide empirical evidence for the validity of these new diagnoses using data from a case–control study of highly health-anxious (n = 96), depressed (n = 52), and healthy (n = 52) individuals. Results: The individuals originally diagnosed as DSM-IV hypochondriasis predominantly met criteria for SSD (74%) and rarely for IAD (26%). Individuals with SSD were more impaired, had more often comorbid panic and generalized anxiety disorders, and had more medical consultations as those with IAD. Yet, no significant differences were found between SSD and IAD with regard to levels of health anxiety, other hypochondriacial characteristics, illness behavior, somatic symptom attributions, and physical concerns, whereas both groups differed significantly from clinical and healthy controls in all of these variables. Conclusion: These results do not support the proposed splitting of health anxiety/hypochondriasis into two diagnoses. Further validation studies with larger samples and additional control groups are warranted to prove the validity of the new diagnoses.     

Differences in negative life events between patients with anxiety disorders,depression and hypochondriasis

This study investigated whether some categories of adverse life events are differentially associated with specific types of emotional disorders. A life self-report measure of major life events was completed by 42 subjects with diagnoses of anxiety disorders, 46 subjects with major depression, 26 subjects with hypochondriasis and 73 nonclinical subjects (controls). As predicted, the onset of anxiety disorders, depression, and hypochondriasis appears to be differentially related with life stress of ‘threat’, ‘loss’, and ‘health’, respectively, previously experienced by the clinical subjects. Also, there were significant differences between clinical and nonclinical subjects on both perceived life stress and number of life events reported. Findings suggest a differential implication of psychosocial stress categories in particular emotional disorders (i.e., anxiety, depressive and hypochondriacal disorders). These results expand previous findings that have demonstrated an association between negative life events and psychopathology.     

The treatment of hypochondriasis: exposure plus response prevention vs cognitive therapy

In this study (1) exposure in vivo plus response prevention, (2) cognitive therapy and (3) a waiting-list control condition were compared on their efficacy on the treatment of hypochondriasis. Seventy-eight patients with a DSM-IV diagnosis of hypochondriasis were randomly assigned to one of these conditions. Patients in both active treatment conditions improved significantly on all the measures, whereas the patients in the waiting-list control condition did not improve. The improvements were clinically significant. Exposure in vivo plus response prevention and cognitive therapy were equally effective. The improvements were maintained at the 7 months follow up.     

Psychoeducation for hypochondriasis: a comparison of a cognitive-behavioural approach and a problem-solving approach

In this study, two 6-week psychoeducational courses for hypochondriasis are compared, one based on the cognitive-behavioural approach, and the other on the problem-solving approach. Effects of both courses on hypochondriacal complaints, depression, trait anxiety, and number of problems encountered in daily life, are measured pre-treatment, post-treatment, and at 1- and 6-month follow-up. Participants (N=48, of whom 4 dropped out), suffering from DSM-IV hypochondriasis, were randomized into one of the two course conditions. Results showed beneficial effects of both courses. Few differential treatment effects were found: in both conditions all effect measures decreased significantly over time (p<0.01). However, between- and inter-individual variability in decrease-patterns was of considerable size, leading to large deviations from the mean pattern. Acceptability and feasibility of both courses were rated highly by their respective participants. It is concluded that both courses can be considered equally beneficial and effective over time, with the effects evident immediately after treatment and maintained over the follow-up period.     

Automatization through Practice: The Opportunistic-Stopping Phenomenon Called into Question

As a theory of skill acquisition, the instance theory of automatization posits that, after a period of training, algorithm-based performance is replaced by retrieval-based performance. This theory has been tested using alphabet-arithmetic verification tasks (e.g., is A + 4  = E?), in which the equations are necessarily solved by counting at the beginning of practice but can be solved by memory retrieval after practice. A way to infer individuals’ strategies in this task was supposedly provided by the opportunistic-stopping phenomenon, according to which, if individuals use counting, they can take the opportunity to stop counting when a false equation associated with a letter preceding the true answer has to be verified (e.g., A + 4  = D). In this case, such within-count equations would be rejected faster than false equations associated with letters following the true answers (e.g., A + 4  = F, i.e., outside-of-count equations). Conversely, the absence of opportunistic stopping would be the sign of retrieval. However, through a training experiment involving 19 adults, we show that opportunistic stopping is not a phenomenon that can be observed in the context of an alphabet-arithmetic verification task. Moreover, we provide an explanation of how and why it was wrongly inferred in the past. These results and conclusions have important implications for learning theories because they demonstrate that a shift from counting to retrieval over training cannot be deduced from verification time differences between outside and within-count equations in an alphabet-arithmetic task.     

The Nature of the Automatization Deficit in Chinese Children with Dyslexia

Clarifying whether automatization deficits constitute the primary causes or symptoms of developmental dyslexia, we focused on three critical issues of the dyslexic automatization deficit, namely universality, domain specificity, and severity. Thirty Chinese dyslexic children (mean age 10 years and 5 months), 30 chronological-age-, and 30 reading-level-matched children were tested in 4 areas of automaticity: motor, visual search, Stroop facilitation effects, and automatic word recognition. The results showed that the dyslexic children performed significantly worse than the CA-controls but not the RL-controls in all the tasks except for Stroop congruent-color words, on which they performed worse than children in both control groups. The deficits reflect a lag in reading experiences rather than a persistent cognitive deficit.     

Anxiety as a context for understanding associations between hypochondriasis, obsessive-compulsive, and panic attack symptoms

In the context of the integrative model of anxiety and depression, we examined whether the essential problem of hypochondriasis is one of anxiety. When analyzed, data from a large nonclinical sample corresponded to the integrative model's characterization of anxiety as composed of both broad, shared and specific, unique symptom factors. The unique hypochondriasis, obsessive-compulsive, and panic attack symptom factors all had correlational patterns expected of anxiety with the shared, broad factors of negative emotionality and positive emotionality. A confirmatory factor analysis showed a higher-order, bifactor model was the best fit to our data; the shared and the unique hypochondriasis and anxiety symptom factors both contributed substantial variance. This study provides refinements to an empirically based taxonomy and clarifies what hypochondriasis is and, importantly, what it is not.     

Cognitive-behavioural approaches in the treatment of hypochondriasis: six single case cross-over studies.

This study evaluates a cognitive and a behavioural treatment protocol for hypochondrical complaints. In a cross-over design, six patients with a primary diagnosis of hypochondriasis were treated. Three of them first received a block of behavioural therapy (exposure in vivo and response prevention), followed by a block of cognitive therapy. The other three patients were first treated with cognitive therapy followed by behavioural therapy. The results were promising: four patients made significant improvements. The behavioural therapy sessions appeared to account more often for improvement than did the cognitive sessions. The sequence of behavioural therapy followed by cognitive therapy tended to be more successful than the other way around. The results of these six case studies suggest that exposure in vivo with response prevention and cognitive therapy may both be useful in the treatment of hypochondriasis. A journal controlled study is recommended.     

Automatization of personal and impersonal discourse with narrative re-telling as a function of age

When older adults retell an impersonal story, the resulting narratives are typically characterized by more prolixity and less coherence than those produced by younger adults. We aimed to determine whether this pattern is also observed when retelling a personal narrative. Younger and older participants told a personal story three consecutive times. With retelling, no evidence of increased coherence or fluency or reduction in hesitancy was observed for either age group. The nature of autobiographical narrative construction explains why such stories are not subject to automatization. A failure to automatize personal narratives is not, therefore, a symptom of aging.     

Acquisition and Automatization of a Complex Task: An Examination of Three-Ball Cascade Juggling

The learning patterns of 3-ball cascade juggling from acquisition until automaticity were examined in 10 participants. On the basis of outcome measures derived from 26 practice sessions and 4 periodic probe sessions, the authors differentiated participants into 3 distinct learning types: a proficient group, an emerging group, and a single late learner. The proficient group was distinguished by how rapidly they learned and automatized performance. Most interesting, an inverse response cost (i.e., performance boost) on the secondary task was found in the majority of proficient group members during the dual-task condition. The present results are discussed in relation to the P. L. Ackerman model (1987, 1988) of complex skill acquisition as is the significance of the inverse response cost finding.