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Holden ML, Gooi CH, Antognelli S, Joubert A, Sabel I, Stavropoulos L, Newby JM. Symptom Attributions in Illness Anxiety Disorder. J Clin Psychol 2025; 81:237-248. [PMID: 39792360 PMCID: PMC11890152 DOI: 10.1002/jclp.23765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 08/14/2024] [Accepted: 12/18/2024] [Indexed: 01/12/2025]
Abstract
OBJECTIVES A major characteristic of health anxiety is the tendency to attribute benign bodily sensations to serious illnesses. This has been supported by empirical research in non-clinical samples, and samples of individuals diagnosed with Hypochondriasis. However, no study to date has explored symptom attribution styles of individuals with the DSM-5 diagnosis of Illness Anxiety Disorder. METHODS Sixty-one participants, including a clinical Illness Anxiety Disorder (n = 35) and healthy control (n = 26) sample, completed self-report measures of health anxiety and an Attribution Task, whereby they were presented with eight common bodily sensations and asked to generate possible explanations for them. RESULTS Results showed that relative to healthy controls, participants with Illness Anxiety Disorder overall were more likely to make more serious, 'catastrophic' somatic attributions to symptoms, and less likely to generate non-threatening normalising explanations. These results also extended to their initial attributions, conceptualised as the 'jumping to conclusions' bias, and as an exploratory index of flexibility, they were also found to make less attributions overall compared to healthy controls. CONCLUSIONS Findings provide support for the cognitive behavioural theory of health anxiety, and highlight the importance of assessing and addressing symptom attributions with clients with illness anxiety disorder.
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Affiliation(s)
| | - Chien H. Gooi
- School of PsychologyUniversity of New South WalesSydneyNSWAustralia
| | | | - Amy Joubert
- Black Dog InstituteUniversity of New South WalesSydneyNSWAustralia
| | - Isaac Sabel
- School of PsychologyUniversity of New South WalesSydneyNSWAustralia
| | | | - Jill M. Newby
- School of PsychologyUniversity of New South WalesSydneyNSWAustralia
- Black Dog InstituteUniversity of New South WalesSydneyNSWAustralia
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Inhibitory Learning-Based Exposure Therapy for Patients With Pathological Health Anxiety: Results From a Single Case Series Study. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Santos ERRD, Silva de Paula JL, Tardieux FM, Costa-e-Silva VN, Lal A, Leite AFB. Association between COVID-19 and anxiety during social isolation: A systematic review. World J Clin Cases 2021; 9:7433-7444. [PMID: 34616809 PMCID: PMC8464456 DOI: 10.12998/wjcc.v9.i25.7433] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/17/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The uncertainties about coronavirus disease 2019 (COVID-19), the change in routine, lifestyles and the reduction of physical contact can cause stress, anxiety, emotional overload, poor sleep and even physical health complications.
AIM To evaluate the scientific publications available on the relationship between COVID-19 and anxiety experienced in the general population, during the period of social isolation, adopted by governmental organizations and public health policymakers as a measure to contain the spread of cases.
METHODS A literature search was performed systematically exploring the PubMed and Medline databases using the following terms classified as MeSH descriptors: (“anxiety” AND “pandemic” AND “COVID-19”). For the search, in the Biblioteca Virtual em Saúde – BVS, Science.gov, Web of Science and National Library platforms, the following keywords were used: ("anxiety" AND "coronavirus" AND "social isolation"). Thirty-seven peer-reviewed articles were found. PRISMA and the Downs & Black checklist were used for qualitative evaluation.
RESULTS After applying the inclusion criteria, seven (n = 7) original scientific articles were selected. The collated evidence demonstrated increased levels of symptoms of anxiety and depression during the period of social isolation. The population between 21 to 40 years was most affected. The risk of severe depression was twice as high at the epicenter of the pandemic. Sleep quality was significantly impaired. Questions about politics, religion, and consumption of products from China were found to generate fear and anticipate probable changes in the pattern of post-pandemic consumption. Social isolation exacerbated feelings of extreme hopelessness, sadness, loneliness and suicidal ideation.
CONCLUSION We conclude that there is a potential relationship between social isolation during the COVID-19 pandemic and symptoms of anxiety. It is important to note that the direct and indirect costs of not identifying the detrimental effects of this phenomenon and neglecting strategies for intervention could lead to a significant psychological burden on society in several aspects after social isolation.
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Affiliation(s)
- Erlene Roberta Ribeiro dos Santos
- Department of Neuropsychiatry and Behavioral Science-Neurosciences, Research Circle on Technologies, Strategies and Instruments Applied to Collective Health, Vitória de Santo Antão 55608680, Brazil
| | - Jose Lucas Silva de Paula
- Department of Collective Health, Research Circle on Technologies, Strategies and Instruments Applied to Collective Health, Vitória de Santo Antão 55608680, Brazil
| | - Felipe Maia Tardieux
- Department of Collective Health, Research Circle on Technologies, Strategies and Instruments Applied to Collective Health, Vitória de Santo Antão 55608680, Brazil
| | | | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Antonio Flaudiano Bem Leite
- Department of Epidemiological Surveillance, Henrique de Holanda, Municipal Health Secretariat, Vitória de Santo Antão 55608680, Brazil
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Maass U, Kühne F, Maas J, Unverdross M, Weck F. Psychological Interventions for Health Anxiety and Somatic Symptoms. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2020. [DOI: 10.1027/2151-2604/a000400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. This study examined the effectiveness of psychological interventions for severe health anxiety (SHA) regarding somatic symptoms (SS) and health anxiety (HA). The databases Web of Science, EBSCO, and CENTRAL were searched on May 15, 2019, May 16, 2019, and August 5, 2019, respectively. Eighteen randomized controlled trials ( N = 2,050) met the inclusion criteria (i.e., hypochondriasis, illness anxiety disorder or somatic symptom disorder with elevated HA being assessed with validated interviews; use of standardized outcome measures). Two reviewers independently evaluated the studies’ risk of bias using the Revised Cochrane Risk-of-Bias Tool for randomized trials (RoB-2) tool. Overall, psychological interventions were significantly more effective than waitlist, treatment-as-usual, or placebo post-treatment ( gSS = 0.70, gHA = 1.11) and at follow-up ( gSS = 0.33, gHA = 0.70). CBT outperformed other psychological interventions or pharmacotherapy for HA post-treatment (Hedge’s gHA = 0.81). The number of sessions did not significantly predict the effect sizes. In sum, psychological interventions were effective for SHA, but the generalizability of the results for SS is limited, because only two high-quality trials contributed to the comparisons.
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Affiliation(s)
- Ulrike Maass
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Franziska Kühne
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Jana Maas
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Maria Unverdross
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
| | - Florian Weck
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Germany
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Witthöft M, Bräscher AK, Jungmann SM, Köteles F. Somatic Symptom Perception and Interoception. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2020. [DOI: 10.1027/2151-2604/a000403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Abstract. Models of chronic somatic symptoms assume that abnormalities in interoception are related to the development and maintenance of symptom distress. Different models, however, disagree on the exact nature of the assumed abnormality: cognitive-behavioral models stress a hypervigilant cognitive style (predicting higher interoceptive accuracy) whereas predictive processing models assume a less detailed sensory processing (predicting lower interoceptive accuracy). This study aimed at testing the relationship between interoception and symptom perception. Using structural equation modeling, associations between cardiac interoception and symptom perception were tested in a sample of students ( n = 316) and a second heterogeneous sample ( n = 340, including 63 patients with either pathological health anxiety or a somatoform disorder according to DSM-IV). Stronger sensory symptom perceptions in the cardiorespiratory system were associated with lower interoceptive accuracy in sample 2. The findings are more in line with the predictive processing approach, suggesting less detailed and more biased interoception being associated with chronic somatic symptom distress.
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Affiliation(s)
- Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Germany
| | - Anne-Kathrin Bräscher
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Germany
| | - Stefanie M. Jungmann
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University of Mainz, Germany
| | - Ferenc Köteles
- Institute of Health Promotion and Sport Sciences, ELTE Eötvös Loránd University, Budapest, Hungary
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Scary symptoms? Functional magnetic resonance imaging evidence for symptom interpretation bias in pathological health anxiety. Eur Arch Psychiatry Clin Neurosci 2019; 269:195-207. [PMID: 28803349 DOI: 10.1007/s00406-017-0832-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/06/2017] [Indexed: 12/21/2022]
Abstract
Patients with pathological health anxiety (PHA) tend to automatically interpret bodily sensations as sign of a severe illness. To elucidate the neural correlates of this cognitive bias, we applied an functional magnetic resonance imaging adaption of a body-symptom implicit association test with symptom words in patients with PHA (n = 32) in comparison to patients with depression (n = 29) and healthy participants (n = 35). On the behavioral level, patients with PHA did not significantly differ from the control groups. However, on the neural-level patients with PHA in comparison to the control groups showed hyperactivation independent of condition in bilateral amygdala, right parietal lobe, and left nucleus accumbens. Moreover, patients with PHA, again in comparison to the control groups, showed hyperactivation in bilateral posterior parietal cortex and left dorsolateral prefrontal cortex during incongruent (i.e., harmless) versus congruent (i.e., dangerous) categorizations of body symptoms. Thus, body-symptom cues seem to trigger hyperactivity in salience and emotion processing brain regions in PHA. In addition, hyperactivity in brain regions involved in cognitive control and conflict resolution during incongruent categorization emphasizes enhanced neural effort to cope with negative implicit associations to body-symptom-related information in PHA. These results suggest increased neural responding in key structures for the processing of both emotional and cognitive aspects of body-symptom information in PHA, reflecting potential neural correlates of a negative somatic symptom interpretation bias.
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Petricone-Westwood D, Jones G, Mutsaers B, Leclair CS, Tomei C, Trudel G, Dinkel A, Lebel S. A Systematic Review of Interventions for Health Anxiety Presentations Across Diverse Chronic Illnesses. Int J Behav Med 2018; 26:3-16. [DOI: 10.1007/s12529-018-9748-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Chapman A, Poliakoff E, Chew-Graham CA, Brown RJ. Attending away from the body predicts increased physical symptom reports at six months in primary care patients. J Psychosom Res 2018; 113:81-88. [PMID: 30190054 DOI: 10.1016/j.jpsychores.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients. METHOD Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores. RESULTS Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months. CONCLUSIONS These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.
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Affiliation(s)
- Anna Chapman
- Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom
| | | | | | - Richard J Brown
- University of Manchester, United Kingdom; University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, United Kingdom.
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Hale AE, Ginsburg GS, Chan G, Kendall PC, McCracken J, Sakolsky D, Birmaher B, Compton S, Marie Albano A, Walkup J. Mediators of Treatment Outcomes for Anxious Children and Adolescents: The Role of Somatic Symptoms. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2018; 47:94-104. [PMID: 28278599 PMCID: PMC6129169 DOI: 10.1080/15374416.2017.1280804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors are effective treatments for pediatric anxiety disorders. However, the mechanisms of these treatments are unknown. Previous research indicated that somatic symptoms are reduced following treatment, but it is unclear if their reductions are merely a consequence of treatment gains. This study examined reductions in somatic symptoms as a potential mediator of the relationship between treatment and anxiety outcomes. Participants were 488 anxious youth ages 7-17 (M = 10.7), 50.4% male, 78.9% Caucasian, enrolled in Child/Adolescent Anxiety Multimodal Study, a large randomized control trial comparing 12-week treatments of CBT, sertraline, a combination of CBT and sertraline, and a pill placebo. Causal mediation models were tested in R using data from baseline, 8-, and 12-week evaluations. Somatic symptoms were assessed using the Panic/Somatic subscale from the Screen for Child Anxiety Related Emotional Disorders. Youth outcomes were assessed using the Pediatric Anxiety Rating Scale and Children's Global Assessment Scale. Reductions in somatic symptoms mediated improvement in anxiety symptoms and global functioning for those in the sertraline-only condition based on parent report. Conditions involving CBT and data based on child reported somatic symptoms did not show a mediation effect. Findings indicate that reductions in somatic symptoms may be a mediator of improvements for treatments including pharmacotherapy and not CBT. Although the overall efficacy of sertraline and CBT for anxiety may be similar, the treatments appear to function via different mechanisms.
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Affiliation(s)
- Amy E. Hale
- University of Connecticut Health Center, 65 Kane St, West Hartford, CT 06119
| | - Golda S. Ginsburg
- University of Connecticut Health Center, 65 Kane St, West Hartford, CT 06119
| | - Grace Chan
- University of Connecticut Health Center, 65 Kane St, West Hartford, CT 06119
| | | | - James McCracken
- UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA
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Mier D, Bailer J, Ofer J, Kerstner T, Zamoscik V, Rist F, Witthöft M, Diener C. Neural correlates of an attentional bias to health-threatening stimuli in individuals with pathological health anxiety. J Psychiatry Neurosci 2017; 42:200-209. [PMID: 28234209 PMCID: PMC5403665 DOI: 10.1503/jpn.160081] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND An attentional bias to health-threat stimuli is assumed to represent the primary pathogenetic factor for the development and maintenance of pathological health anxiety (PHA; formerly termed "hypochondriasis"). However, little is known about the neural basis of this attentional bias in individuals with PHA. METHODS A group of patients with PHA, a group of depressed patients and a healthy control group completed an emotional Stroop task with health-threat (body symptom and illness) words and neutral control words while undergoing functional MRI. RESULTS We included 33 patients with PHA, 28 depressed patients and 31 controls in our analyses. As reflected in reaction times, patients with PHA showed a significantly stronger attentional bias to health-threat words than both control groups. In addition, patients with PHA showed increased amygdala and rostral anterior cingulate cortex activation for body symptom, but not for illness words. Moreover, only in patients with PHA amygdala activation in response to symptom words was positively associated with higher arousal and more negative valence ratings of the body symptom word material. LIMITATIONS A control group of patients with an anxiety disorder but without PHA would have helped to define the specificity of the results for PHA. CONCLUSION The attentional bias observed in patients with PHA is associated with hyperactivation in response to body symptom words in brain regions that are crucial for an arousal-related fear response (e.g., the amygdala) and for resolving emotional interference (e.g., the rostral anterior cingulate cortex). The findings have important implications for the nosological classification of PHA and suggest the application of innovative exposure-based interventions for the treatment of PHA.
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Affiliation(s)
- Daniela Mier
- Correspondence to: D. Mier, Department of Clinical Psychology, Central Institute of Mental Health, J5, 68159 Mannheim, Germany;
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Bailer J, Witthöft M, Erkic M, Mier D. Emotion dysregulation in hypochondriasis and depression. Clin Psychol Psychother 2017; 24:1254-1262. [PMID: 28444850 DOI: 10.1002/cpp.2089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 03/17/2017] [Accepted: 03/23/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aim of this study was to explore whether certain aspects of emotion dysregulation (i.e., facets of alexithymia and rumination) are more closely linked to hypochondriasis than to depression and vice versa. METHODS Nineteen patients with hypochondriasis (HYP), 33 patients with depression, and 52 healthy control participants completed the Toronto Alexithymia Scale, the Response Styles Questionnaire, and additional symptom and illness behaviour scales. A clinical interview was used to establish DSM-IV diagnoses and to exclude all cases with more than one axis I diagnosis. RESULTS Depression patients reported more difficulties describing feelings and more symptom- and self-focused rumination than both HYP patients and healthy individuals, whereas HYP patients differed only from healthy individuals in regard to more difficulties in identifying feelings and more symptom-focused rumination. Multiple regression analyses, including all assessed facets of emotion dysregulation, showed that the degree of somatoform features (somatic symptoms, health anxiety, and illness behaviour) was specifically predicted by higher difficulties in identifying feelings scores, whereas depressive symptom levels were specifically predicted by higher rumination scores. CONCLUSIONS Specific associations were found between difficulties in identifying feelings and key features of HYP, whereas depression was linked to a more generalized pattern of emotion regulation deficits. KEY PRACTITIONER MESSAGE Emotion dysregulation can be found in hypochondriasis and depression Difficulties in identifying own feelings are specifically linked to somatic symptoms, health anxiety, and illness behaviour, whereas a more generalized pattern of emotion dysregulation is found in relation to depression Further research is needed to investigate whether the effectiveness of current treatments for depression, hypochondriasis, health anxiety, and related disorders could be improved by additional emotion regulation interventions.
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Affiliation(s)
- Josef Bailer
- Department of Clinical Psychology, Central Institute of Mental Health, Medical Faculty Mannheim, University Heidelberg, Mannheim, Germany
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, University of Mainz, Mainz, Germany
| | - Maja Erkic
- Department of Clinical Psychology, Central Institute of Mental Health, Medical Faculty Mannheim, University Heidelberg, Mannheim, Germany
| | - Daniela Mier
- Department of Clinical Psychology, Central Institute of Mental Health, Medical Faculty Mannheim, University Heidelberg, Mannheim, Germany
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Abstract
PURPOSE OF REVIEW Self-reported bodily symptoms are of primary importance in healthcare and in health-related research. Typically, they are assessed in clinical interviews or by means of traditional questionnaire formats that require the respondent to provide retrospective symptom estimates rated along intuitive frequency and/or intensity standards and aggregated across varying or unspecified time windows. RECENT FINDINGS Retrospective symptom assessments are often biased when compared to (averaged) momentary assessments of symptoms. A variety of factors and conditions have been identified to influence the amount of bias in symptom reporting. Recent research has focused on the underlying mechanisms for the discrepancy between memory and experience. It is suggested that different types of questions and formats assess different types of information, and each may be relevant for different purposes. Knowledge of these underlying mechanisms also provides a relevant framework to better understand individual differences in symptom reporting, including somatoform and somatic symptom disorder. SUMMARY Accuracy of self-reported bodily symptoms is important for the clinician and the researcher. Understanding the mechanisms underlying bias may provide an interesting window to understand how symptom episodes are processed, encoded, and consolidated in memory and may also provide clues to modify symptom experiences.
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The Effects of Attention Training on Health Anxiety: An Experimental Investigation. COGNITIVE THERAPY AND RESEARCH 2015. [DOI: 10.1007/s10608-015-9745-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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