Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles

Increased understanding of the nature and role of intrusive imagery has contributed to the development of effective treatment protocols for some anxiety disorders. However, intrusive imagery in severe health anxiety (hypochondriasis) has been comparatively neglected. Hence, the current study investigates the prevalence, nature and content of intrusive imagery in 55 patients who met DSM-IV-TR (APA, 2000) criteria for the diagnosis of hypochondriasis. A semi-structured interview was used to assess the prevalence, nature and possible role of intrusive imagery in this disorder. Over 78% of participants reported experiencing recurrent, distressing intrusive images, the majority (72%) of which either were a memory of an earlier event or were strongly associated with a memory. The images tended to be future orientated, and were reliably categorised into four themes: i) being told ‘the bad news’ that you have a serious/life threatening-illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%). Participants reported responding to experiencing intrusive images by engaging in avoidance, checking, reassurance seeking, distraction and rumination. Potential treatment implications and links to maintenance cycles are considered.     

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.     

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.     

Developing new treatments: on the interplay between theories, experimental science and clinical innovation

It is often argued that behaviour therapy and cognitive-behaviour therapy have a sound theoretical and experimental basis. In the early days of behaviour therapy, the learning theory accounts that were the basis of treatment made clear suggestions about the procedures that were likely to be effective in treatment. In contrast, more recent cognitive-behavioural models tend to specify targets for therapy, but not the procedures that might be optimal for changing the targets. As a consequence, a considerable amount of work has to be done in order to create an effective cognitive-behavioural treatment from a promising cognitive-behavioural model. The process by which cognitive-behavioural treatments are developed is rarely discussed in the literature. For this reason, the way in which one group has used a mixture of phenomenological, experimental and treatment development studies to create effective cognitive therapy programmes for anxiety disorders is described.     

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 feature-positive effect and hypochondriacal concerns

There is evidence to suggest that people have more problems with processing information that is absent (negative information) than with present (positive) information. This bias of overweighing positive and underweighing negative information has been termed the "feature-positive effect" (FPE). Typically, hypochondriasis is characterized by excessive focusing on bodily complaints (cf. positive information), and at the same time discarding negative medical test results (cf. negative information). It was explored whether the FPE is involved in this pattern. Fifty-three undergraduates completed a measure of hypochondriacal concerns and a general, domain-free test of the FPE. As expected, a positive correlation between the FPE and hypochondriacal concerns was observed. Implications for cognitive-behavioural theory are discussed.     

The effects of safety behaviors on health anxiety: an experimental investigation

The present study examined the extent to which safety behaviors exacerbate symptoms of hypochondriasis (severe health anxiety). Participants were randomized into a safety behavior (n = 30) or control condition (n = 30). After a baseline period, participants in the safety behavior condition spent one week actively engaging in a clinically representative array of health-related safety behaviors on a daily basis, followed by a second week-long baseline period. Participants in the control condition monitored their normal use of safety behaviors. Compared to control participants, those in the safety behavior condition reported significantly greater increases in health anxiety, hypochondriacal beliefs, contamination fear, and avoidant responses to health-related behavioral tasks after the safety behavior manipulation. In contrast, general anxiety symptoms did not significantly differ between the two groups as a function of the manipulation. Mediational analyses were consistent with the hypothesis that changes in the frequency of health-related thoughts mediated the effects of the experimental manipulation on health anxiety. These findings suggest that safety behaviors are associated with increases in health anxiety, perhaps by fostering catastrophic thoughts about health. The implications of these findings for the conceptualization of hypochondriasis as an anxiety disorder are discussed.     

Gender differences in health anxiety: An investigation of the interpersonal model of health anxiety

Health anxiety (HA) involves persistent worry about one’s health and beliefs one has an illness or may contract a disease. In the present study, gender differences in Noyes et al.’s (2003) interpersonal model of health anxiety (IMHA) were examined. Using a sample of 950 undergraduates (674 women; 276 men), multigroup confirmatory factor analyses suggested the measurement model for key dimensions of the IMHA (i.e., reassurance-seeking, alienation, worry, and absorption) were invariant across gender. This suggests key dimensions of this model are applicable to and generalizable across women and men. Coefficients alpha for and bivariate correlations between these IMHA dimensions were also roughly comparable across women and men. As hypothesized, mean levels of reassurance-seeking and worry were significantly higher in women compared to men. No gender differences were observed in mean levels of alienation or absorption. Reassurance-seeking and worry appear salient in the interpersonal behavior and emotional life of women with HA. The present study helps to clarify gender differences in the IMHA and other HA models involving similar variables.