Dimensionality of the Whiteley Index: assessment of hypochondriasis in an Australian sample of primary care patients

Short report: Early-onset health anxiety: Insights from a cross-sectional study on adults diagnosed with severe health anxiety

OBJECTIVE

The knowledge of early-onset health anxiety (HA) (i.e. onset before age 18) is limited. This retrospective study aimed to investigate 1) the age of onset of HA and 2) potential clinical factors associated with early- compared with late-onset HA in adult patients with severe HA.

METHODS

The study sample consisted of 126 adults (aged 20-60 years) diagnosed with severe HA and referred to specialized treatment. All underwent semi-structured diagnostic interviews assessing psychiatric disorders and functional somatic disorders. The interview also included a detailed illness history with a chronological listing of HA symptom onset. Self-reports were obtained on current HA symptoms, illness perceptions, and treatment expectations.

RESULTS

Early onset of HA was reported by 40 participants (32 %, 95 % CI: 24 %-41 %) with a mean age at symptom onset of 11.6 years (SD: 4.0, range: 5-17), and 23 participants reported onset before age 13 (57.5 %). Early-onset HA was significantly associated with more negative perceptions of consequences of symptoms (Cohen's d = 0.41, p = 0.04) and stronger psychological attributions (Cohen's d = 0.33, p = 0.03), and the group with early onset were more often diagnosed with severe functional somatic disorders (Cramer's V = 0.17, p = 0.06) and reported more negative treatment expectations (Cramer's V = 0.17, p = 0 0.06), although these results were non-significant.

CONCLUSION

Early onset of HA may be common and associated with more negative illness perceptions in adulthood. These results need replication but highlight the need for further research on HA in youth.

Assessment of psychosocial aspects in adults in post-COVID-19 condition: the EURONET-SOMA recommendations on core outcome domains for clinical and research use

BACKGROUND

Harmonizing core outcome domains allows for pooling data, comparing interventions, and streamlining research evaluation. At the same time clinicians require concise and feasible measures for routine practice. Considering the heterogeneity of post-COVID-19 condition, a biopsychosocial approach requires sufficient coverage of the psychosocial dimension with assessments. Previous recommendations for core outcome sets have serious limitations regarding the psychosocial aspects of post-COVID-19 condition. This paper specifically focuses on psychosocial outcomes for adults with post-COVID-19 condition, providing both a comprehensive set of outcome domains for research and a streamlined clinical core set tailored for routine clinical use.

METHODS

In a structured Consensus Development Approach, the European Network to improve diagnostic, treatment, and healthcare for patients with persistent somatic symptoms (EURONET-SOMA) developed psychosocial core outcome domains and assessments regarding post-COVID-19 condition. The experts identified variables and instruments which should be considered in studies on adults suffering from post-COVID-19 condition, and which are feasible in the clinical setting and relevant for research.

RESULTS

We identified three higher-order dimensions with each encompassing several domains: The first higher-order dimension, "outcomes", encompasses (1) the classification/ diagnostics of post-COVID-19 condition, (2) somatic symptoms (including fatigue), (3) the psychopathological status and mental comorbidities, (4) the physical status and somatic comorbidities, (5) neurocognitive symptoms, and (6) illness consequences. The second higher-order domain "mechanisms" encompasses (7) cognitive components, (8) affective components, (9) behavioral components, (10) social components, and (11) psychobiological bridge markers (e.g., neuroimmunological and psychoneuroendocrinological variables). The third higher-order domain, "risk factors", includes factors such as (12) socioeconomic status and sociocultural factors, (13) pre-existing mental and somatic health issues, (14) personality factors (e.g., neuroticism), (15) adverse childhood experiences, (16) ongoing disability or pension claim, and (17) social media use. For each domain, specific instruments are suggested for research purposes and clinical use.

CONCLUSIONS

The recommended core domains help to increase consistency in a biopsychosocial approach to post-COVID-19 condition across investigations, improve synergies, and facilitate decision-making when comparing different interventional approaches. It allows to better identify relevant subgroups in heterogeneous post-COVID-19 condition populations offering practical tools for routine clinical practice through the clinical core set.

Further Evidence for a Dimensional Latent Structure of Health Anxiety: Taxometric Analyses of the Whiteley Index Based on Two German Representative Samples

Health anxiety is an intricate part of illness anxiety and somatic symptom disorder. Based on convenience samples, two out of three available studies indicate that it is a dimensional rather than a categorical construct. Using two representative datasets, this study investigates whether previous results can be clarified. Conventional taxometric analyses as well as comparison curve fit indices (CCFI) profile analyses (MAMBAC and MAXSLOPE procedures) were calculated with two datasets of the German adult population assessing the Whiteley Index (WI-14, N = 2,072; WI-7, N = 2,498). Mean CCFIs indicated a dimensional structure for both the WI-7 (mean CCFI = 0.42, mean CCFI profile = 0.40) and the WI-14 (mean CCFI = 0.44, mean CCFI profile = 0.32). The results support and extend previous findings by strongly suggesting a dimensional distribution of health anxiety in the general population. Implications for research and practice comprise the adoption of a dimensional description of psychopathology as well as transdiagnostic treatment approaches.

Diagnostic accuracy of the Dutch version of the Somatic Symptom Disorder - B Criteria Scale (SSD-12) compared to the Whiteley Index (WI) and PHQ-15 in a clinical population

OBJECTIVE

Somatic Symptom and Related Disorders(SSRD) are characterised by an intense focus on somatic symptoms that causes significant distress. A self-report scale developed to assess distress as symptom-related thoughts, feelings, and behaviors (SSD-12) has proved to be a reliable, valid and time-efficient measure for Somatic Symptom Disorder(SSD). This cross-sectional study aimed to compare the SSD-12 with psychiatric assessment as gold standard in a Dutch clinical population for SSRD compared to other widely used measures.

METHODS

Data were collected from adult patients visiting a specialised mental health outpatient clinic for SSRD in the Netherlands, between 2015 and 2017. Analyses included item evaluation, scale reliability, construct validity, diagnostic utility and cut points. Performance of SSD-12, Whiteley Index(WI) and PHQ-15 were compared in Receiver operating characteristics (ROC) curves.

RESULTS

223 patients with SSD, Functional Neurological Disorder, Illness Anxiety(IA) and no SSRD participated. SSD-12 items were normally distributed; total scores correlated with measures of health anxiety, anxiety and depression. The optimal cut point for the SSD-12 was 22 (sensitivity 75.9%, specificity 63.6%). The ROC area under the curve for SSD-12 was 0.75 compared to 0.68 for the WI and 0.65 for the PHQ-15. Combinations of those questionnaires did not yield better results than for the SSD-12 alone.

CONCLUSION

The SSD-12 alone outperformed the WI and PHQ-15 and combined scales in effectively distinguishing SSRDs from other mental disorders. This may suggest that distress is a more accurate indicator of SSRD than earlier diagnostic criteria as operationalised in the WI and PHQ-15.

Resting-state connectivity and neural response to emotional images in patients with severe health anxiety: An fMRI study

BACKGROUND

Severe health anxiety is a disorder characterized by a persistent preoccupation with one's health. In behavioral studies, biases in the processing of health-related stimuli (e.g., pictures, words) are consistently associated with health anxiety symptoms. The neural correlates of the observed behavioral abnormalities remain however poorly understood.

METHODS

In this functional magnetic resonance imaging study, 22 treatment-seeking patients with severe health anxiety and 22 control participants performed a resting-state and a picture matching task. Immediately after the resting-state, participants completed a questionnaire quantifying their thoughts and feelings during rest along several dimensions. The picture task included images of health-related and neutral scenes and of disgusted and neutral faces.

RESULTS

Compared to controls, patients with health anxiety showed increased functional connectivity in the dorsolateral prefrontal cortex within the left fronto-parietal resting-state network, which correlated positively with the self-reported thought dimensions of Self, Health Concern, and Thought Suppression. In the picture matching task, no significant group differences were found in the hypothesised regions (amygdala and insula) or at a whole-brain level in response to either health-related versus neural scenes or disgust versus neutral faces contrasts.

LIMITATIONS

A relatively small sample size and that no information about patients declining to participate was obtained.

CONCLUSIONS

Our findings suggest that behavioral biases in health anxiety may be related to aberrant left dorsolateral prefrontal cortex functional connectivity at rest. In contrast, the health anxiety patients did not show significant hyperactivations of amygdala and insula during processing of emotional stimuli, contrasting findings in other anxiety disorders.

Adverse childhood experiences in patients with severe health anxiety: No evidence for an increased frequency compared to patients with obsessive-compulsive disorder

Theoretical models of health anxiety emphasize adverse childhood experiences in the development of the disorder, but few studies examine such events in patients with severe health anxiety and the results are difficult to compare across studies. The present study examined adult retrospective reports of illness-related and traumatic childhood experiences in 31 patients with severe health anxiety, 32 non-clinical control participants, and a clinical control group of 33 patients with obsessive-compulsive disorder. No evidence of an increased frequency of adverse childhood experiences in patients with severe health anxiety was found. However, patients with severe health anxiety who had experienced the death of a friend or family member or a major upheaval during childhood, perceived these events as having been more traumatic than the control participants. These findings suggest that biases in how adverse childhood experiences are interpreted or remembered might play a role in severe health anxiety. The findings are discussed in relation to the cognitive behavioral model of health anxiety, and some of the processes in interpretation and memory that could explain how adverse childhood experiences might play a role in the development and maintenance of severe health anxiety are outlined.

Health Anxiety and Its Correlates in the General Chinese Population During the COVID-19 Epidemic

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has had an adverse impact on the mental health of the general population. This study aimed to investigate the prevalence and correlates of health anxiety (HA) in the general Chinese population to inform psychological interventions in COVID-19-affected areas. Methods: We conducted an online survey of the general population in mainland China between 6 and 17 February 2020 (N = 1,450, 69.79% female; mean age = 37.5 ± 9.1 years). The Whiteley Index-7 (WI-7), COVID-19 knowledge quiz (CKQ), Generalised Anxiety Disorder scale (GAD-7), Patient Health Questionnaire Depression Scale (PHQ-9), and socio-demographic information were surveyed using the Questionnaire-Star program. Results: The prevalence of HA, depression and anxiety were 47.3, 31.3, and 35.7%, respectively. The WI-7 score showed a significant association with age, education level, income, occupation, chronic disease and daily time focused on COVID-19. On binary logistic regression analysis, individuals with masters or higher qualification degree [odds ratio (OR) = 0.632)], older age (OR = 0.981), 2-4 h daily time focused on COVID-19 (OR = 0.684), healthcare workers (OR = 0.749, p = 0.046) and those with more COVID-19 related knowledge (OR = 0.785) showed a significantly negative association with HA. Chronic disease (OR = 1.962), depression (OR = 1.05) and anxiety (OR = 1.228) were significant risk factors for HA. Conclusions: HA was highly prevalent among the general population during the early stages of the COVID-19 outbreak. More than two-fifths of the respondents had obvious HA. Chronic disease, depression and anxiety were risk factors for HA; psychological interventions offered during the pandemic should pay particular attention to these individuals.

Psychometric Evaluation of the Whiteley Index-8 in Chinese Outpatients in General Hospitals

Background: Excessive and persistent health anxiety is a common and disabling but often unrecognized illness. Therefore, screening patients for health anxiety is recommended in primary care. The aim of the present study was to examine the psychometric properties of an updated version of the eight-item Whiteley Index (WI-8) among outpatients in general hospitals in China. Methods: The presented data were derived from a multicenter cross-sectional study. The Chinese version of the WI-8 was administered to a total of 696 outpatients. Cronbach's alpha was used to evaluate the internal consistency of the scale. The validity of the scale was evaluated based on factor analysis and correlation analyses. To assess the discriminant ability, receiver operating characteristic (ROC) analysis was conducted. Results: Cronbach's alpha was 0.937, and it decreased (0.925) after deleting the new 8th item. Factor analysis extracted one factor accounting for 69.2% of the variance. Moderate correlations were found (0.414-0.662) between the WI-8 and General Anxiety Disorder (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder B-criteria (SSD-12). The ROC curve indicated excellent discriminatory ability to discriminate among patients with health anxiety (AUC = 0.822). Conclusions: The new WI-8 version is a reliable and valid tool to screen for health anxiety in general hospital patients. We recommend the WI-8 as a useful screening tool for health anxiety.

Message sharing and verification behaviour on social media during the COVID-19 pandemic: a study in the context of India and the USA

Purpose

Technology has eased access to information. During the ongoing COVID-19 pandemic, ease of access and transmission of information via social media has led to ambiguity, misinformation and uncertainty. This research studies the aforementioned behaviours of information sharing and verification related to COVID-19, in the context of social media.

Design/methodology/approach

Two studies have been carried out. Study 1, with Indian social media users, is a two-factor between-subjects experimental design that investigated the effect of message polarity (positive versus negative) and message type (news versus rumour) on the dissemination and verification behaviour of COVID-19-related messages. The study also investigated the mediation of perceived message importance and health anxiety. Study 2 is a replica study conducted with US users.

Findings

The study finding revealed significantly higher message sharing for news than rumour. Further, for the Indian users, message with positive polarity led to higher message sharing and message with negative polarity led to higher verification behaviour. On the contrary, for the US users, message with negative polarity led to higher message sharing and message with positive polarity led to higher verification behaviour. Finally, the study revealed message importance mediates the relationship of message type and message sharing behaviour for Indian and US users; however, health anxiety mediation was significant only for Indian users.

Practical implications

The findings offer important implications related to information regulation during a health crisis. Unverified information sharing is harmful during a pandemic. The study sheds light on this behaviour such that stakeholders get insights and better manage the information being disseminated.

Originality/value

The study investigates the behaviour of sharing and verification of social media messages between users containing health information (news and rumour) related to the ongoing COVID-19 pandemic.

Peer review

The peer review history for this article is available at: https://publons.com/publon/10.1108/OIR-07-2020-0282

Fear of Cancer Recurrence, Health Anxiety, Worry, and Uncertainty: A Scoping Review About Their Conceptualization and Measurement Within Breast Cancer Survivorship Research

Objective: Fear of Cancer Recurrence (FCR), Health Anxiety (HA), worry, and uncertainty in illness are psychological concerns commonly faced by cancer patients. In survivorship research, these similar, yet different constructs are frequently used interchangeably and multiple instruments are used in to measure them. The lack of clear and consistent conceptualization and measurement can lead to diverse or contradictory interpretations. The purpose of this scoping review was to review, compare, and analyze the current conceptualization and measurements used for FCR, HA, worry, and uncertainty in the breast cancer survivorship literature to improve research and practice. Inclusion Criteria: We considered quantitative, qualitative, and mixed methods studies of breast cancer survivors that examined FCR, HA, worry, or uncertainty in illness as a main topic and included a definition or assessment of the constructs. Methods and Analysis: The six-staged framework was used to guide the scoping review process. Searches of PubMed, CINAHL, and PsycINFO databases were conducted. The principle-based qualitative analysis and simultaneous content analysis procedures were employed to synthesize and map the findings. Findings: After duplicate removal, the search revealed 3,299 articles, of which 82 studies met the inclusion criteria. Several critical attributes overlapped the four constructs, for example, all were triggered by internal somatic and external cues. However, several unique attributes were found (e.g., a sense of loss of security in the body is observed only among survivors experiencing FCR). Overall, findings showed that FCR and uncertainty in illness are more likely to be triggered by cancer-specific factors, while worry and HA have more trait-like in terms of characteristics, theoretical features, and correlates. We found that the measures used to assess each construct were on par with their intended constructs. Eighteen approaches were used to measure FCR, 15 for HA, 8 for worry, and 4 for uncertainty. Conclusion: While consensus on the conceptualization and measurement of the four constructs has not yet been reached, this scoping review identifies key similarities and differences to aid in their selection and measurement. Considering the observed overlap between the four studied constructs, further research delineating the unique attributes for each construct is warranted.

Detection of illness worry in the general population: A specific item on illness rumination improves the Whiteley Index

OBJECTIVE

The Whiteley Index (WI) is the most widely used screening tool for health anxiety/illness worry. Diverse versions (different number of items and factors) have been used. We aimed to examine psychometric properties of 7 items of the WI besides adding a new item on obsessive illness rumination for better future detection of health anxiety.

METHODS

Data from a large population-based study in Denmark (N = 9656). Construct validity was examined by exploratory (EFA) and confirmatory factor analysis (CFA) plus hypothesis testing. Criterion validity was evaluated via Receiver Operating Characteristic curves and area under the curve (AUC) using a diagnostic criterion as gold standard.

RESULTS

Factor loadings of EFA revealed viable one-factor models (6, 7, or 8 items) and two-factor models (7 or 8 items). Factor one indicated a dimension of illness worry. Factor two indicated a somatic symptoms dimension. The new item on obsessive illness rumination merged well with the existing items. EFA of two-factor models and one-factor 6-item model showed good fit. CFA resembles these findings. A one-factor 6-item model (including the item on obsessive illness rumination and excluding two items concerning somatic symptoms) was chosen as the optimal model and presented good criterion validity: AUC 0.88 (95%CI(0.84;0.92)). Main hypotheses concerning associations with somatic symptoms, anxiety, and depression were met.

CONCLUSIONS

We found good psychometric properties for a new one-factor 6-item version of the WI. Through elimination of items concerning somatic symptoms and inclusion of obsessive illness rumination, we propose a clear, unidimensional and improved measure of illness worry: Whiteley-6-R.

Health anxiety and attentional bias toward virus-related stimuli during the COVID-19 pandemic

After the COVID-19 worldwide spread, evidence suggested a vast diffusion of negative consequences on people's mental health. Together with depression and sleep difficulties, anxiety symptoms seem to be the most diffused clinical outcome. The current contribution aimed to examine attentional bias for virus-related stimuli in people varying in their degree of health anxiety (HA). Consistent with previous literature, it was hypothesized that higher HA would predict attentional bias, tested using a visual dot-probe task, to virus-related stimuli. Participants were 132 Italian individuals that participated in the study during the lockdown phase in Italy. Results indicated that the HA level predicts attentional bias toward virus-related objects. This relationship is double mediated by the belief of contagion and by the consequences of contagion as assessed through a recent questionnaire developed to measure the fear for COVID-19. These findings are discussed in the context of cognitive-behavioral conceptualizations of anxiety suggesting a risk for a loop effect. Future research directions are outlined.

Feasibility of group-based acceptance and commitment therapy for adolescents (AHEAD) with multiple functional somatic syndromes: a pilot study

BACKGROUND

Recurrent and impairing functional somatic syndromes (FSS) are common in adolescents. Despite a high need for care, empirically supported treatments are lacking for youth. The aim of this uncontrolled pilot study was to assess feasibility and treatment potential of a new intervention with group-based Acceptance and Commitment Therapy (ACT) in a generic treatment approach for adolescents with multiple FSS.

METHODS

Twenty-one patients received 'ACT for Health in Adolescents' (AHEAD) (30 h), specifically developed for adolescents (aged 15-19 years) with moderate to severe FSS. Close relatives attended an information meeting to facilitate support of the patients throughout treatment. Treatment satisfaction was evaluated by means of self-report and relatives' impressions. Self-reported physical health at 3 months follow-up (FU) after end of treatment was the primary outcome whereas secondary outcomes included symptom burden, limitation due to symptoms, illness worry, emotional distress and physical and emotional symptoms. Treatment targets were assessed by measures on illness behaviour, illness perception and psychological inflexibility.

RESULTS

Nineteen patients (90.5%) completed the treatment with a high overall attendance rate of 93%. All would recommend the treatment to a friend with similar problems. Close relatives rated it valuable to participate in an information meeting. Patients' physical health improved significantly from assessment to FU with a clinically relevant mean change of 8.9 points (95% CI [5.4; 12.4]; SRM 0.91 [0.26;1.57]). Improvement was also seen on all secondary outcome measures, from assessment to FU. Maladaptive illness behaviours and perceptions as well as psychological inflexibility showed a significant decline from assessment to FU.

CONCLUSION

AHEAD was feasible and potentially efficacious and warrants testing in a larger clinical trial.

TRIAL REGISTRATION

Clinical Trials gov NCT04464447 , registration date July 9th, 2020. Retrospectively registered.

Examining the Moderating Role of Patient Enablement on the Relationship Between Health Anxiety and Psychosomatic Distress: A Cross-Sectional Study at a Traditional Chinese Medicine Outpatient Clinic in Hong Kong

Background

Little research effort has been devoted to examining the role of patient enablement in alleviating health anxiety in primary care. In this study, we examined the role of patient enablement as a moderator in the relationship between health anxiety, psychological distress, and treatment seeking in traditional Chinese medicine (TCM).

Methods

The participants were 634 patients of a government-subsidized Chinese medicine outpatient clinic in Hong Kong. They were asked to complete a series of questionnaires on patient enablement, health anxiety, anxiety, depression, physical distress, annual clinic visits, and service satisfaction and provided various demographic details. Descriptive statistics, correlations, and general linear models were used to analyze the data.

Results

We found that patient enablement correlated positively with service satisfaction. Patient enablement also interacted significantly with health anxiety in affecting indices of psychological distress (depression, anxiety) and treatment seeking (annual visits). Among highly enabled patients, the positive association between health anxiety and indices of psychological distress was weakened, and they also showed more health anxiety-driven treatment seeking as measured by annual clinic visits.

Conclusion

These findings suggest a moderating mechanism by which patient enablement weakens the relationship between health anxiety on psychological well-being and increases treatment-seeking behavior in TCM. Practitioners are encouraged to provide sufficient information to patients to foster self-care and disease self-management using complementary and alternative medicine (CAM).

Distinct associations of DSM-5 Somatic Symptom Disorder, the Diagnostic Criteria for Psychosomatic Research-Revised (DCPR-R) and symptom severity in patients with irritable bowel syndrome

OBJECTIVE

The clinical management of high symptom severity is a challenging task with patients with functional somatic disorders. We investigated the extent to which DCPR-revised (DCPR-R) syndromes and the DSM-5 category of Somatic Symptom Disorder (SSD) were able to predict symptom severity in 203 consecutive tertiary care patients with irritable bowel syndrome (IBS).

METHOD

Semistructured interview were used for assessing DCPR-R and validated scales for SSD (combining PHQ-12 and WI-7), severity of symptoms (IBS-SSS), psychological distress (HADS), and psychosocial functioning (SF-12).

RESULTS

Compared to moderate severity (IBS-SSS = 175-300), patients in the high range of severity (IBS-SSS > 300) had significantly more DCPR-R syndromes (particularly alexithymia and persistent somatization), higher psychological distress, and poorer psychosocial functioning, but showed no difference for SSD. DCPR-R, particularly alexithymia and persistent somatization, significantly and independently predicted IBS severity by explaining 18.5% of the IBS-SSS variance with large effect size (d = 1.18), after controlling for covariables. Conversely, SSD was not able to significantly predict IBS severity.

CONCLUSIONS

This study highlights the need of an integrative approach in the medical setting. Psychosomatic factors play a relevant role in the individual perception of symptom severity and should be carefully evaluated for clinical management of functional syndromes.

Patients with Multiple Functional Gastrointestinal Disorders (FGIDs) Show Increased Illness Severity: A Cross-Sectional Study in a Tertiary Care FGID Specialty Clinic

OBJECTIVES

Overlaps between different functional gastrointestinal disorders (FGIDs) are common. However, little is known about the impact of this overlap on patients' health status. This study is aimed at analyzing the differences between patients with multiple as compared to one single FGID.

METHODS

A retrospective, cross-sectional study was conducted with patients presenting to a tertiary care FGID specialty clinic between 06/2012 and 01/2015 (n = 294). They were characterized primarily according to their GI symptom severity (IBS-SSS) and secondarily to their physical as well as psychosocial symptom burden, quality of life, health care utilization, and work-related impairment. Differences between patients with >1 vs. 1 FGID were analyzed.

RESULTS

Of the 294 patients, 92.2% fulfilled the Rome III criteria for any FGID, and 48.0% had >1 FGIDs. FGID patients had a median age of 38 [23.0] years; 72.0% were female. Median GI symptom severity (IBS-SSS) scores were 339 [126] and 232 [163] in patients with >1 and 1 FGID, respectively (p < .001). Furthermore, patients with >1 FGIDs had higher general somatic symptom severity, higher illness anxiety, lower quality of life, and more work-related impairment. Almost no differences were found regarding their somatic as well as mental comorbidities.

CONCLUSIONS

Multiple FGIDs are associated with an increased risk for complicated courses of illness as reflected in higher GI and somatic symptom severity, as well as stronger psychosocial and diet- and work-related impairment. Stepped and interdisciplinary models of care including psychosocial expertise and dietary advice are needed, especially for patients with multiple FGIDs.

Relationship between adverse childhood experiences and illness anxiety in irritable bowel syndrome - The impact of gender

OBJECTIVE

Irritable bowel syndrome (IBS) is a functional disorder with a complex biopsychosocial etiopathogenesis. Various psychosocial factors like adverse childhood experiences (ACE) and illness anxiety appear to be relevant, but underlying mechanisms are still not fully understood. Furthermore, there are indicators of gender specific effects of ACE on IBS. Therefore, this study analyzed group differences between IBS patients and healthy controls (HCs) according to ACE and illness anxiety, and the relationship between ACE and illness anxiety by taking gender differences into consideration.

METHODS

A cross-sectional multi-center study was conducted comparing IBS patients with HCs. Illness anxiety was recorded using the Whiteley-Index-7, childhood adversities via the 10-item Adverse-Childhood-Experiences-score, anxiety by the Generalized Anxiety Disorder seven-item questionnaire and depressive symptoms using the nine-item depression module of the patient-health-questionnaire. Group differences between IBS patients and HCs were analyzed and correlation analyses were performed.

RESULTS

Overall, 127 gender and education matched participants per group were included. Compared to HCs, IBS patients were characterized by higher prevalences for adverse childhood experiences (63.8% vs. 48.0%, p = .02, OR = 1.33) and increased levels of illness anxiety (p < .001, η² = 0.595). Taking into account gender specific effects, there was a significant correlation between adverse childhood experiences and illness anxiety in female IBS patients, but not in male (r = 0.242, p = .03 vs. r = 0.162, p = .29). However, after controlling for depression and anxiety, this correlation disappeared.

CONCLUSION

Our findings suggest a possible gender-specific association of ACE with illness anxiety in female IBS patients that might be linked to increased levels of depression and anxiety.

TRIAL REGISTRATION

DRKS00011685.

Examining the Whiteley Index-6 as a screener for DSM-5 presentations of severe health anxiety in primary care

Psychological screening is essential within primary care settings, with growing evidence that health anxiety could be important to screen for in such settings. Brief screeners in primary care settings are considered most viable for routine use. This study provided the first known examination of a version of the Whiteley Index (WI; Pilowksy, 1967) as a screener for primary care patients who are experiencing DSM-5 presentations of severe health anxiety (i.e., somatic symptom disorder, illness anxiety disorder). A six-item short form of the WI (i.e., WI-6), with item responses made using an ordered-category response option, was examined. Consecutively enrolled U.S. patients presenting for treatment at a community health center (N = 202) completed the WI-6 and a semi-structured interview assessing clinically severe health anxiety in the form of somatic symptom disorder and illness anxiety disorder. A total of 61 participants met criteria for clinically severe health anxiety and were compared to patients who did not meet criteria for clinically severe health anxiety. Results from a receiver operating characteristic (ROC) analysis indicated that a cutoff score of 18 on the WI-6 adequately balanced sensitivity (75%) and specificity (77%). The area under the curve (AUC) indicated the WI-6 did a reasonable job discriminating between the two groups (AUC = 0.83, p < .001, 95% confidence interval = 0.77-0.89). Study results offer preliminary support for the WI-6 as a practical screener for identifying cases of severe health anxiety in U.S. primary care settings that may warrant further evaluation.

When Do People Verify and Share Health Rumors on Social Media? The Effects of Message Importance, Health Anxiety, and Health Literacy

This study explores the roles of perceived message importance, health anxiety, and health literacy in the relationship between message factors (message label and message valence) and behavioral intentions for rumor verification and sharing. 660 Twitter users responded to unverified information regarding the influenza vaccine. A 3 (label: none vs. news vs. rumor) × 2 (valence: positive vs. negative) online semi-experiment, with a survey to measure health anxiety and health literacy, showed the following results: First, perceived message importance mediated the relationship between message factors and behavioral intentions: only in the condition of the negative message, participants considered a news-labeled message more important than a rumor-labeled or a no-label message. Perceived message importance was associated with intentions to verify and share the message. Second, health anxiety interacted with perceived message importance only when predicting an intention to share the message. Last, healthy literacy interacted with perceived message importance when predicting intentions to both verify and share the message. The results will provide implications for health communication research and practices, especially on managing and controlling rumor dissemination on social media.

Why is the recognition rate of psychological distress under-estimated in general hospitals? A cross-sectional observational study in China

This study aimed to investigate the recognition rate of psychological distress in general hospitals in China and to examine the main associated factors.Using a cross-sectional study design, the questionnaires were administered to a total of 1329 inpatients from a tertiary hospital. The Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire (PHQ-15) and the Whiteley-7 (WI-7) were used to assess patients' mental health status. Two subjective questions were used to identify the awareness of psychological distress in patients and doctors.The frequency of psychological distress measured by the questionnaires was high in our sample (53.4%). However, the recognition rates of both patients (34.9%) and by doctors (39.1%) was low. The concordance rate between patients and doctors of whether the patient had psychological distress or not was extremely poor (Kappa = 0.089, P = .001). Factors associated with the poor concordance rate included patients' annual household income and clinically significant self-reported symptoms of anxiety and hypochondriasis.The recognition rate of psychological distress was underestimated and this may be related to a lack of awareness of mental disturbances and patients' low annual household income.

Encoding and retrieval biases for health-related scenes in patients with severe health anxiety

Severe health anxiety is a disorder characterised by excessive worries about harbouring or having a serious illness. The present study examines cognitive biases in evaluation and memory for health-related scenes in severe health anxiety in order to provide insights into the effect of these biases and the formation of illness intrusions in severe health anxiety. Twenty patients with severe health anxiety and 20 healthy participants completed a computerised task consisting of encoding, involuntary retrieval, voluntary retrieval and recognition of health-related, negative and neutral scenes. The results demonstrated that patients with severe health anxiety reported more negative emotional valence and greater physiological arousal to health-related scenes, both during encoding (ps < .031, ηp2  > .09) and retrieval (ps < .044, ds > 0.18). Furthermore, in contrast to the comparison group, patients with severe health anxiety did not show shorter retrieval time for health-related scenes during involuntary compared with voluntary retrieval (p = .789, d = 0.08), possibly due to greater demands on emotion regulation during involuntary retrieval. The results suggest an important role for negative emotional valence and physiological arousal to health-related stimuli in severe health anxiety, and highlight how cognitive biases in evaluation and memory might be at play in this disorder.

Feasibility Study of Group Cognitive Behavioral Therapy for Severe Health Anxiety

Severe health anxiety (SHA) is prevalent, often undiagnosed, persistent untreated, and costly. Meta-analyses have shown effectiveness of mostly individual cognitive behavioral therapy (CBT), whereas Group-CBT has only been studied and shown feasibility in one uncontrolled study of psychiatric outpatients also including self-referrals. We aimed to examine feasibility of Group-CBT for physician-referred psychiatric outpatients with SHA and a future randomized controlled trial (RCT). Group-CBT was conducted in two groups of seven participants. Feasibility was examined about recruitment rate, attrition, organization, and effectiveness. Effectiveness was measured by standardized self-report questionnaires: Whiteley Index-7 (WI-7) and Short Health Anxiety Inventory, and clinician rated remission and functioning from baseline to 3-month follow-up (3FU). Recruitment rate was 1.4 participant per month. Attrition showed dropout of 7%. Organization harbored only one senior therapist. Group-CBT showed effectiveness on all measures except WI-7 at 3FU; this latter explained by participants with concurrent borderline personality disorder. Group-CBT seems feasible for physician-referred psychiatric outpatients with SHA. With modifications, an RCT seems feasible.

A Twelve-Week Moderate Exercise Programme Improved Symptoms of Depression, Insomnia, and Verbal Learning in Post-Aneurysmal Subarachnoid Haemorrhage Patients: A Comparison with Meningioma Patients and Healthy Controls

OBJECTIVES

Deficits in psychological functioning, cognitive functioning, and sleep are frequently experienced by individuals who have survived aneurysmal subarachnoid haemorrhage (aSAH). Exercise has been shown to improve these domains; to date, it has never been explored in patients following aSAH. The aim of this exploratory study is to compare the effects of an exercise programme in this population with another patient group, and a group of healthy controls.

METHODS

The present study explored the effects of 12 weeks of moderate aerobic exercise training on 15 aSAH patients, 16 meningioma patients, and 17 healthy controls. Data on symptoms of depression, hypochondria, perceived stress, satisfaction with life, verbal learning and memory, and subjective and objective sleep, were gathered at baseline, following intervention, and at 6-month follow-up.

RESULTS

aSAH patients and meningioma patients had decreased symptoms of depression and insomnia at follow-up. While perceived stress decreased in the meningioma group, in aSAH patients it increased. Total learning performance increased in all three groups.

CONCLUSIONS

An exercise programme had a positive effect on symptoms of depression, insomnia, and verbal learning in patients following aSAH. No positive changes in other domains were observed. This may be due to the cautious approach taken with regard to exercise intensity.

Core Outcome Domains for Clinical Trials on Somatic Symptom Disorder, Bodily Distress Disorder, and Functional Somatic Syndromes: European Network on Somatic Symptom Disorders Recommendations

OBJECTIVE

The harmonization of core outcome domains in clinical trials facilitates comparison and pooling of data, and simplifies the preparation and review of research projects and comparison of risks and benefits of treatments. Therefore, we provide recommendations for the core outcome domains that should be considered in clinical trials on the efficacy and effectiveness of interventions for somatic symptom disorder, bodily distress disorder, and functional somatic syndromes.

METHODS

The European Network on Somatic Symptom Disorders group of more than 20 experts in the field met twice in Hamburg to discuss issues of assessment and intervention research in somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. The consensus meetings identified core outcome domains that should be considered in clinical trials evaluating treatments for somatic symptom disorder and associated functional somatic syndromes.

RESULTS

The following core domains should be considered when defining ascertainment methods in clinical trials: a) classification of somatic symptom disorder/bodily distress disorder, associated functional somatic syndromes, and comorbid mental disorders (using structured clinical interviews), duration of symptoms, medical morbidity, and prior treatments; b) location, intensity, and interference of somatic symptoms; c) associated psychobehavioral features and biological markers; d) illness consequences (quality of life, disability, health care utilization, health care costs; e) global improvement and treatment satisfaction; and f) unwanted negative effects.

CONCLUSIONS

The proposed criteria are intended to improve synergies of clinical trials and to facilitate decision making when comparing different treatment approaches. These recommendations should not result in inflexible guidelines, but increase consistency across investigations in this field.

Screening for DSM-5 Somatic Symptom Disorder: Diagnostic Accuracy of Self-Report Measures Within a Population Sample

OBJECTIVE

The new DSM-5 somatic symptom disorder was introduced to improve the diagnosis of persons experiencing what used to be called somatoform disorders. So far, it is unclear whether existing self-report measures are useful to detect the new somatic symptom disorder. This study investigates the diagnostic accuracy of three self-report questionnaires that measure somatic complaints (15 item Patient Health Questionnaire [PHQ-15]) and psychological features (7-item Whiteley Index [WI-7]; Scale for Assessing Illness Behavior [SAIB]), in detecting somatic symptom disorder.

METHODS

A nationally representative general population survey was performed resulting in 250 participants (minimum age = 14 years. 12.8% participation rate). Assessment took place at baseline and 12-month follow-up. Individual and combined diagnostic accuracy of the PHQ-15, WI-7, and SAIB in detecting somatic symptom disorder was evaluated using the area under the curve (AUC) of a receiver operating characteristic.

RESULTS

Diagnostic accuracy was adequate to good for each individual questionnaire (PHQ-15: AUC = 0.79, p < .001, 95% confidence interval [CI] = 0.73-0.85; WI-7: AUC = 0.76, p < .001, 95% CI = 0.69-0.83; SAIB: AUC = 0.77, p < .001, 95% CI = 0.71-0.83). Combining the PHQ-15 and the WI-7 slightly improved diagnostic accuracy (AUC = 0.82, p < .001, 95% CI = 0.77-0.88), as did the combination of all three questionnaires (AUC = 0.85, p < .001, 95% CI = 0.79-0.90).

CONCLUSIONS

The PHQ-15, WI-7, and SAIB are useful screening instruments to detect persons at risk for somatic symptom disorder, and a combination of these three instruments slightly improves diagnostic accuracy. Their use in routine care will lead to improved detection rates.

Development and Feasibility Testing of Internet-Delivered Acceptance and Commitment Therapy for Severe Health Anxiety: Pilot Study

BACKGROUND

Severe health anxiety (hypochondriasis), or illness anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, is characterized by preoccupation with fear of suffering from a serious illness in spite of medical reassurance. It is a debilitating, prevalent disorder associated with increased health care utilization. Still, there is a lack of easily accessible specialized treatment for severe health anxiety.

OBJECTIVE

The aims of this paper were to (1) describe the development and setup of a new internet-delivered acceptance and commitment therapy (iACT) program for patients with severe health anxiety using self-referral and a video-based assessment; and (2) examine the feasibility and potential clinical efficacy of iACT for severe health anxiety.

METHODS

Self-referred patients (N=15) with severe health anxiety were diagnostically assessed by a video-based interview. They received 7 sessions of clinician-supported iACT comprising self-help texts, video clips, audio files, and worksheets over 12 weeks. Self-report questionnaires were obtained at baseline, post-treatment, and at 3-month follow-up. The primary outcome was Whiteley-7 Index (WI-7) measuring health anxiety severity. Depressive symptoms, health-related quality of life (HRQoL), life satisfaction, and psychological flexibility were also assessed. A within-group design was employed. Means, standard deviations, and effect sizes using the standardized response mean (SRM) were estimated. Post-treatment interviews were conducted to evaluate the patient experience of the usability and acceptability of the treatment setup and program.

RESULTS

The self-referral and video-based assessments were well received. Most patients (12/15, 80%) completed the treatment, and only 1 (1/15, 7%) dropped out. Post-treatment (14/15, 93%) and 3-month follow-up (12/15, 80%) data were available for almost all patients. Paired t tests showed significant improvements on all outcome measures both at post-treatment and 3-month follow-up, except on one physical component subscale of HRQoL. Health anxiety symptoms decreased with 33.9 points at 3-month follow-up (95% CI 13.6-54.3, t₁₁= 3.66, P=.004) with a large within-group effect size of 1.06 as measured by the SRM.

CONCLUSIONS

Treatment adherence and potential efficacy suggest that iACT may be a feasible treatment for health anxiety. The uncontrolled design and small sample size of the study limited the robustness of the findings. Therefore, the findings should be replicated in a randomized controlled trial. Potentially, iACT may increase availability and accessibility of specialized treatment for health anxiety.

TRIAL REGISTRATION

Danish Data Protection Agency, Central Denmark Region: 1-16-02-427-14; https://www.rm.dk/sundhed/faginfo/forskning/datatilsynet/ (Archived by Webcite at http://www.webcitation.org/6yDA7WovM).

Testing a biopsychosocial model of the basic birth beliefs

BACKGROUND

Women perceive what birth is even before they are pregnant for the first time. Part of this conceptualization is the basic belief about birth as a medical and natural process. These two separate beliefs are pivotal in the decision-making process about labor and birth. Adapting Engel's biopsychosocial framework, we explored the importance of a wide range of factors which may contribute to these beliefs among first-time mothers.

METHOD

This observational study included 413 primiparae ≥24 weeks' gestation, recruited in medical centers and in natural birth communities in Israel. The women completed a questionnaire which included the Birth Beliefs Scale and a variety of biopsychosocial characteristics such as obstetric history, birth environment, optimism, health-related anxiety, and maternal expectations.

RESULTS

Psychological dispositions were more related to the birth beliefs than the social or biomedical factors. Sociodemographic characteristics and birth environment were only marginally related to the birth beliefs. The basic belief that birth is a natural process was positively related to optimism and to conceiving spontaneously. Beliefs that birth is a medical process were related to pessimism, health-related anxiety, and to expectations that an infant's behavior reflects mothering. Expectations about motherhood as being naturally fulfilling were positively related to both beliefs.

CONCLUSION

Psychological factors seem to be most influential in the conceptualization of the beliefs. It is important to recognize how women interpret the messages they receive about birth which, together with their obstetric experience, shape their beliefs. Future studies are recommended to understand the evolution of these beliefs, especially within diverse cultures.

Pilot-RCT of an integrative group therapy for patients with refractory irritable bowel syndrome (ISRCTN02977330)

OBJECTIVE

Different forms of psychotherapeutic treatments have been proven effective in irritable bowel syndrome (IBS), but disorder-oriented and integrative concepts are still rare. Therefore, we implemented and evaluated an integrative group therapeutic concept within an interdisciplinary tertiary care clinic for functional gastrointestinal disorders (FGIDs).

AIMS

present our integrative group concept, assess feasibility issues, and evaluate efficacy.

METHODS

A pilot-RCT with a randomized controlled wait-listed group design was conducted. The treatment concept was a disorder-oriented multicomponent group therapy (12 90-min weekly sessions) integrating interactive psychoeducation, gut-directed hypnotherapy, and open group phases. All patients received enhanced medical care and completed a short online diary as an active wait-listed control condition.

INCLUSION CRITERIA

refractory IBS diagnosed as somatoform autonomic dysfunction of the lower gastrointestinal tract (SAD).

PRIMARY OUTCOME

IBS symptom severity (IBS-SSS).

RESULTS

Of 294 patients, 220 had IBS (ROME III), 144 were diagnosed as SAD (ICD-10), 51 were eligible regarding inclusion/exclusion criteria, and 30 consented to participate (group intervention: n=16, wait-listed control condition: n=14). Only 1 patient dropped out. Intention-to-treat-analysis with repeated-measures mixed ANOVA showed that the group intervention was not significantly superior to the wait-listed control condition. Nevertheless, the calculated effect size for the between-group difference in IBS-SSS at the end of treatment (post) was moderate (d=0.539).

CONCLUSION

Our disorder-oriented integrative group intervention for IBS proved to be acceptable and feasible in an interdisciplinary tertiary care setting. There is promise in this intervention, but a larger RCT may be needed to investigate efficacy.

Health anxiety by proxy in women with severe health anxiety: A case control study

Health anxiety (HA) refers to excessive worries and anxiety about harbouring serious illness based on misinterpretation of bodily sensations or changes as signs of serious illness. Severe HA is associated with disability and high health care costs. However, the impact of parental HA on excessive concern with their children's health (health anxiety by proxy) is scantly investigated. The aim of this study is to investigate HA by proxy in mothers with severe HA. Fifty mothers with severe HA and two control groups were included, i.e. mothers with rheumatoid arthritis (N=49) and healthy mothers (N=51). All participants completed self-report questionnaires on their own HA and illness perceptions and on illness worries and illness behaviour related to their children. The results showed that mothers with severe HA reported significantly more negative illness perceptions and more HA on behalf of their child (i.e. by proxy) compared to both control groups. HA by proxy may be an overlooked treatment target in mothers with severe HA, and improving our understanding of this condition can have important preventive and clinical implications.

Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients

BACKGROUND & OBJECTIVES

While cognitive behaviour therapy (CBT) is an established treatment for health anxiety, there are barriers to service access. Internet-delivered cognitive behaviour therapy (ICBT) has demonstrated effectiveness and has the potential to improve access to treatment. Nevertheless, it is unknown how patients perceive ICBT relative to other interventions for health anxiety and what factors predict ICBT acceptability. This study investigated these questions.

METHODS

Primary care patients (N = 116) who reported elevated levels of health anxiety were presented three treatment vignettes that each described a different protocol for health anxiety (i.e., medication, CBT, ICBT). Acceptability and credibility of the treatments were assessed following the presentation of each vignette. Participants then ranked the three treatments and provided a rational for their preferences.

RESULTS

The treatments were similarly rated as moderately acceptable. Relative to medication and ICBT, CBT was perceived as the most credible treatment for health anxiety. The highest preference ranks were for CBT and medication. Regression analyses indicated that lower computer anxiety, past medication use, and lower ratings of negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability.

LIMITATIONS

Health anxiety was not assessed with a diagnostic interview. Primary care patients were recruited through a Qualtrics panel. Patients did not have direct experience with treatment but learned about treatment options through vignettes.

CONCLUSIONS

Medication and CBT are preferred over ICBT. If ICBT is to increase treatment access, methods of improving perceptions of this treatment option are needed.

Operationalization of diagnostic criteria of DSM-5 somatic symptom disorders

BACKGROUND

The aim of this study was to test the operationalization of DSM-5 somatic symptom disorder (SSD) psychological criteria among Chinese general hospital outpatients.

METHODS

This multicenter, cross-sectional study enrolled 491 patients from 10 general hospital outpatient departments. The structured clinical "interview about cognitive, affective, and behavioral features associated with somatic complaints" was used to operationalize the SSD criteria B. For comparison, DSM-IV somatoform disorders were assessed with the Mini International Neuropsychiatric Interview plus. Cohen's к scores were given to illustrate the agreement of the diagnoses.

RESULTS

A three-structure model of the interview, within which items were classified as respectively assessing the cognitive (B1), affective (B2), and behavioral (B3) features, was examined. According to percentages of screening-positive persons and the receiver operator characteristic (ROC) analysis, a cut-off point of 2 was recommended for each subscale of the interview. With the operationalization, the frequency of DSM-5 SSD was estimated as 36.5% in our sample, and that of DSM-IV somatoform disorders was 8.2%. The agreement between them was small (Cohen's к = 0.152). Comparisons of sociodemographic features of SSD patients with different severity levels (mild, moderate, severe) showed that mild SSD patients were better-off in terms of financial and employment status, and that the severity subtypes were congruent with the level of depression, anxiety, quality of life impairment, and the frequency of doctor visits.

CONCLUSIONS

The operationalization of the diagnosis and severity specifications of SSD was valid, but the diagnostic agreement between DSM-5 SSD and DSM-IV somatoform disorders was small. The interpretation the SSD criteria should be made cautiously, so that the diagnosis would not became over-inclusive.

Predictors of illness anxiety symptoms in patients with obsessive compulsive disorder

Illness anxiety and OCD symptoms appear to overlap in their presentation as well as in other conceptually important ways (e.g., dysfunctional cognitions). Little research, however, has directly examined these putative relationships. The present study examined the extent to which illness anxiety symptoms were associated with OCD symptom dimensions and relevant cognitive factors in a large treatment-seeking sample of patients with OCD. Patients completed a battery of self-report measures of OCD and health anxiety symptoms and related cognitive biases. Results from regression analyses indicated that illness anxiety symptoms were associated with harm obsessions and checking rituals, as well as with the tendency to overestimate threat and responsibility for harm. Illness anxiety was not associated with perfectionism. Conceptual and clinical implications of these findings are discussed.

Psychometric Properties of the Worry Behaviors Inventory: Replication and Extension in a Large Clinical and Community Sample

BACKGROUND

The use of maladaptive behaviors by individuals with generalized anxiety disorder (GAD) is theoretically important and clinically meaningful. However, little is known about the specificity of avoidant behaviors to GAD and how these behaviors can be reliably assessed.

AIMS

This study replicated and extended the psychometric evaluation of the Worry Behaviors Inventory (WBI), a brief self-report measure of avoidant behaviors associated with GAD.

METHOD

The WBI was administered to a hospital-based sample of adults seeking treatment for symptoms of anxiety and/or depression (n = 639) and to a community sample (n = 55). Participants completed measures of symptom severity (GAD, depression, panic disorder, health anxiety, and personality disorder), and measures of checking, reassurance-seeking and behavioral inhibition. Analyses evaluated the factor structure, convergent, divergent, incremental, and discriminant validity, as well the temporal stability and treatment sensitivity of the WBI.

RESULTS

The two-factor structure found in the preliminary psychometric evaluation of the WBI was replicated. The WBI was sensitive to changes across treatment and correlated well with measures of GAD symptom severity and maladaptive behaviors. The WBI was more strongly related to GAD symptom severity than other disorders. The WBI discriminated between clinical and community samples.

CONCLUSIONS

The WBI provides clinicians and researchers with a brief, clinically meaningful index of problematic behaviors that may guide treatment decisions and contribute to our understanding of maintaining factors in GAD.

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.

Sleep Quality, Sleep EEG Pattern, Mental Well-Being and Cortisol Secretion in Patients with Ruptured Aneurysm Post-Treatment: A Comparison with Post-Surgery Meningioma Patients and Controls

BACKGROUND

Although the chance of surviving an aneurysmal subarachnoid haemorrhage (aSAH) has increased steadily, disturbed sleep and persistent psychological complaints are frequently experienced post-ictus. To date, however, few studies have sought to determine whether physiological parameters, such as objectively measured sleep and cortisol secretion, interrelate significantly with low sleep quality and psychological complaints such as depression. Furthermore, there is little evidence as to whether post-ictal complaints differ between aSAH patients and other groups who have experienced stressful medical intervention.

METHODS

Data on objective and subjective sleep, sleep-related dysfunctional cognitions, psychological functioning and cortisol secretion were collected from 15 patients who had undergone medical intervention for aSAH. Data were also collected from a group of 16 individuals who had undergone surgery for a meningioma and a third group made up of 17 healthy participants.

RESULTS

aSAH patients and meningioma patients had significantly poorer subjective sleep than healthy controls and reported more sleep-related dysfunctional cognitions and hypochondriacal beliefs. They also had a significantly higher morning cortisol response. Finally, a non-significant trend was found showing that aSAH patients and meningioma patients reported poorer psychological functioning than healthy controls.

CONCLUSION

Following treatment, aSAH patients and meningioma patients experience poorer subjective sleep and some differences in objectively measured sleep, which might be attributable to increased sleep-related dysfunctional cognitions and poorer overall psychological functioning. Differences in cortisol production were also observed, suggesting that some physiological imbalances are still present post-ictus.

Psychological and somatic distress in Chinese outpatients at general hospitals: a cross-sectional study

BACKGROUND

Our study aimed (1) to describe the proportion of psychological distress among Chinese outpatients at general hospitals, (2) to compare cognitive and behavioral characteristics of patients with different distress patterns, and (3) to investigate the discriminant function of the analyzed variables in indicating the affinity towards the different distress patterns.

METHODS

This multicenter cross-sectional study was conducted at ten outpatient departments at Chinese general hospitals. The somatic symptom severity scale (PHQ-15), the nine-item depression scale (PHQ-9), and the seven-item anxiety scale (GAD-7) were employed to classify patients in terms of four distress patterns.

RESULTS

A total of 491 patients were enrolled. Among them, the proportion of patients with high psychological distress was significantly higher within those with high somatic distress (74.5% vs. 25.5%, p < .001). Patients with psychological distress alone and mixed distress were significantly younger and with lower monthly family income, while the proportion of female patients (80.9%) was highest in the somatic distress group. Patients with mixed distress had the most negative cognitive and behavioral characteristics [highest health anxiety (5.0 ± 1.9), lowest sense of coherence (35.5 ± 10.0), the worst doctor-patient relationship from both patients' (36.0 ± 7.3) and doctors' perspectives (23.3 ± 7.0)], as well as most impaired quality of life (41.6 ± 7.4 and 31.9 ± 10.3). In addition, compared with patients with somatic distress alone, those with psychological distress alone had lower sense of coherence, worse doctor-patient relationship, and more impaired mental quality of life, but less doctor visits. Discriminant analysis showed that gender, mental quality of life, health anxiety, sense of coherence, and frequent doctor visits were significant indicators in identifying patients with different distress patterns.

CONCLUSIONS

Our study found that (1) psychological distress was not rare in the Chinese general hospital outpatients, especially in those with high somatic distress; (2) patients with psychological distress alone sought less help from doctors, despite their severe psychosocial impairment; and (3) gender, health anxiety, sense of coherence, mental quality of life, and frequent doctor visits could help to identify different distress patterns.

Pilot trial of a therapist-supported internet-delivered cognitive behavioural therapy program for health anxiety

Cognitive behavioural therapy (CBT) is an effective treatment for health anxiety, but more research is needed to evaluate accessible, low cost ways of delivering CBT. Internet CBT may be effective, but there are no iCBT programs available outside of Sweden. We developed the first English-language clinician-guided iCBT program for health anxiety and conducted an open pilot trial (n = 16) to examine its acceptability, and impact on health anxiety and comorbidity, disability, and the cognitive and behavioural factors thought to maintain the disorder (e.g., catastrophising, hypervigilance). 13/16 participants completed the program (81% adherence). We found large and significant reductions in health anxiety, depression, distress, anxiety and disability (g's > 1.0), dysfunctional cognitions, behaviours and body vigilance between pre- and post-treatment, which were maintained at 3-month follow-up. The results provide preliminary support for the use of iCBT for health anxiety. Randomised controlled efficacy trials are now needed to evaluate this program.

Psychological distress and personality factors in takotsubo cardiomyopathy

Background

Takotsubo cardiomyopathy (TCC) is a transient condition characterised by severe left ventricular dysfunction combined with symptoms and signs mimicking myocardial infarction. Emotional triggers are common, but little is known about the psychological background characteristics of TCC. This study examined whether patients with TTC have higher levels of psychological distress (depressive symptoms, perceived stress, general anxiety), illness-related anxiety and distinct personality factors compared with healthy controls and patients with heart failure.

Methods and Results

Patients with TCC (N = 18; mean age 68.3 ± 11.7 years, 77.8 % women) and two comparison groups (healthy controls: N = 19, age 60.0 ± 7.6, 68.4 % women and patients with chronic heart failure: N = 19, age 68.8 ± 10.1, 68.4 % women) completed standardised questionnaires to measure depression (PHQ‑9), perceived stress (PSS-10), general anxiety (GAD-7), illness-related anxiety (WI-7) and personality factors (NEO-FFI and DS-14). Psychological measures were obtained at 23 ± 18 months following the acute TTC event. Results showed that patients with TCC had higher levels of depressive symptoms (5.2 ± 5.2 vs. 2.5 ± 2.4, p = 0.039) and illness-related anxiety (2.1 ± 1.7 vs. 0.7 ± 1.3, p = 0.005) compared with healthy controls. Patients with TCC did not display significantly elevated perceived stress (p = 0.072) or general anxiety (p = 0.170). Regarding personality factors, levels of openness were lower in TCC compared with healthy controls (34.2 ± 4.3 vs. 38.2 ± 5.6, p = 0.021). No differences between TCC and heart failure patients were found regarding the psychological measures.

Conclusions

TCC is associated with higher levels of depressive symptoms, more illness-related anxiety and less openness compared with healthy controls. These data suggest that TCC is associated with adverse psychological factors that may persist well after the acute episode.

Health-Related Anxiety and Hypochondriacal Concerns in Medical Students: A Cross-Sectional Study From Pakistan

Phenomenon: Transient health-related anxiety/hypochondriacal concerns in medical students are well documented. The literature suggests that after studying a particular disease, medical students are likely to consider any symptoms earlier regarded as normal to be signs of the disease they are studying. The aim of this study was to investigate the prevalence of these phenomena and their cognitive and distress aspects among medicals students in Karachi, Pakistan.

APPROACH

This was an analytical, cross-sectional study. Self-administered questionnaires comprising demographic details, the Short Health Anxiety Inventory, Medical Students' Disease (MSD) Perception Scale, and MSD Distress Scale were distributed to 1st- through 5th-year medical students.

FINDINGS

In total, 513 medical students (66% female) participated. Their mean age was 21 ± 1.6 years. Three hundred seventy-five students (73%) reported having visited a doctor at least once in the past 6 months. Fifty students (9.9%) admitted to having addictions. The overall prevalence of significant hypochondriacal concerns was 11.9% (61 students). The presence of addiction was associated with a greater likelihood of developing significant health-related anxiety (odds ratio = 3.82, p = .003), 95% confidence interval [1.51, 7.11]. Age, gender, medical school, year of medical school, and visits to the doctor in the previous 6 months were not associated with greater likelihood of developing significant health-related anxiety. Second-year medical students experienced a significantly greater degree of worry (MSD-Distress scale) than 5th-year students (M score = 12.6 ± 4.6 vs. 10.7 ± 4.4, p = .04). Insights: The prevalence of substantial hypochondriacal concerns in medical students in Pakistan was low in comparison to similar studies published in literature. Student health physicians should be aware of the true prevalence of hypochondriacal concerns and behavior and not dismiss legitimate complaints. Educational sessions to counteract this phenomenon can be incorporated into the curriculum of undergraduate medicine. By defining heightened awareness of symptoms as a normal process, different coping techniques can be discussed to help medical students reduce their level of stress.

Application of the Chinese Version of the Whiteley Index-7 for Detecting DSM-5 Somatic Symptom and Related Disorders

BACKGROUND

The Whiteley Index-7 (WI-7) is frequently used for evaluating patients with suspected hypochondriasis. However, information about its use on somatic symptom and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is still lacking. This study investigated the psychometric properties of the Mandarin Chinese version of the WI-7 and its application to evaluation of somatic symptom and related disorders.

METHODS

Participants completed the WI-7 and received diagnostic interview based on both Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and DSM-5 criteria. Exploratory factor analysis was performed, and the test-retest reliability and the internal consistency of the WI-7 were assessed. Receiver Operating Characteristic curves were established, and the area under the curve was calculated to determine the cutoff point to distinguish DSM-IV somatoform disorders and DSM-5 somatic symptom and related disorders, respectively.

RESULTS

A total of 471 subjects were recruited for this study. The exploratory factor analysis of the WI-7 identified a single factor. The internal consistency and test-retest reliability of the WI-7 were 0.829 and 0.836, respectively. The area under Receiver Operating Characteristic curve using WI-7 to distinguish DSM-5 somatic symptom and related disorders is 0.660, higher than that when applying to distinguish DSM-IV somatoform disorders. The sensitivity and specificity at an optimal cutoff point of 0/1 are 0.645 and 0.675, respectively.

CONCLUSION

The Mandarin Chinese version of the WI-7 is a potentially useful tool to detect individuals with DSM-5 somatic symptom and related disorders.

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.

Optimal cut-off points on the health anxiety inventory, illness attitude scales and whiteley index to identify severe health anxiety

BACKGROUND

Health anxiety can be viewed as a dimensional phenomenon where severe health anxiety in form of DSM-IV hypochondriasis represents a cut-off where the health anxiety becomes clinically significant. Three of the most reliable and used self-report measures of health anxiety are the Health Anxiety Inventory (HAI), the Illness Attitude Scales (IAS) and the Whiteley Index (WI). Identifying the optimal cut-offs for classification of presence of a diagnosis of severe health anxiety on these measures has several advantages in clinical and research settings. The aim of this study was therefore to investigate the HAI, IAS and WI as proximal diagnostic instruments for severe health anxiety defined as DSM-IV hypochondriasis.

METHODS

We investigated sensitivity, specificity and predictive value on the HAI, IAS and WI using a total of 347 adult participants of whom 158 had a diagnosis of severe health anxiety, 97 had obsessive-compulsive disorder and 92 were healthy non-clinical controls. Diagnostic assessments were conducted using the Anxiety Disorder Interview Schedule.

RESULTS

Optimal cut-offs for identifying a diagnosis of severe health anxiety was 67 on the HAI, 47 on the IAS, and 5 on the WI. Sensitivity and specificity were high, ranging from 92.6 to 99.4%. Positive and negative predictive values ranged from 91.6 to 99.4% using unadjusted prevalence rates.

CONCLUSIONS

The HAI, IAS and WI have very good properties as diagnostic indicators of severe health anxiety and can be used as cost-efficient proximal estimates of the diagnosis.

Psychometric properties of Internet-administered measures of health anxiety: an investigation of the Health Anxiety Inventory, the Illness Attitude Scales, and the Whiteley Index

BACKGROUND

The Health Anxiety Inventory (HAI), the Illness Attitude Scales (IAS), and the Whiteley Index (WI) are three of the most widely used health anxiety measures, but their psychometric properties have not been investigated when administered via the Internet.

METHODS

We investigated the three instruments' test-retest reliability, internal consistency, convergent, and discriminant validity and sensitivity to change using one sample (n=111) of participants with severe health anxiety and one sample of healthy controls (n=92).

RESULTS

The HAI, IAS, and WI showed high test-retest reliability (rs≥.80), good convergent, and discriminant validity and were sensitive to detect change. The HAI and IAS (αs≥.85), but not the WI (αs≤.60) demonstrated high internal consistency.

CONCLUSIONS

The HAI, IAS, and WI have good psychometric properties, except for the low internal consistency of WI, when used as Internet-administered measures of health anxiety. Using these measures over the Internet offers highly important advantages such as increased ease of administration, reduced attrition, and cost-efficient treatment evaluation.

Somatic symptom burden and health anxiety in the population and their correlates

OBJECTIVE

Somatic symptom burden and health anxiety demonstrate overlapping clinical characteristics but their relationship in the general population is unclear. This study examined the association between these dimensions after adjustment for confounders and their respective correlation with outcome measures.

METHODS

A randomly selected population-based sample of 3014 respondents aged 15-65 was interviewed by telephone using a structured questionnaire that included the 15-item Patient Health Questionnaire (PHQ-15), Whiteley-7, Kessler-6, Sheehan Disability Scale, socio-demographic variables and items regarding health care utilization. Respondents who scored 10 or above on PHQ-15 and 4 or above on Whiteley-5 were regarded as having high somatic symptom burden and high health anxiety respectively.

RESULTS

Somatic symptom burden and health anxiety are moderately correlated after adjustment for confounders (p<.001). Both have important effects on psychological distress, functional impairment and health care utilization independent of each other (ps<.001). A considerable number of respondents (5.7%) reported both high somatic symptom burden and high health anxiety and this group showed the greatest general psychological distress, functional impairment and health care utilization.

CONCLUSION

This study demonstrates the close association of somatic symptom burden and health anxiety but also their independent association with psychological distress, functional impairment and health care utilization. The findings support the concept of the DSM-5 category of somatic symptom disorder, but also demonstrate that individuals with high somatic symptom burden or high health anxiety alone may merit separate diagnoses. More sophisticated studies of the relationship between somatic symptom burden and health anxiety are needed.