Heather D. Hadjistavropoulos

Cognitive and behavioral responses to illness information : the role of health anxiety

The cognitive-behavioral theory of health anxiety predicts atypical responses in health anxious individuals when exposed to health related information. Systematic research is still needed to support the theory. This investigation examined 192 participants varying a subclinical levels of health anxiety, who were randomly given feedback on an ostensible diagnostic measure, indicating positive, negative or ambiguous risk for health complications. Responses to a cold pressor task were then measured. The results indicated that regardless of the type of feedback patients were given, health anxious individuals displayed the predicted cognitive (e.g. negatively interpreted information) and behavioral responses (e.g. increased reassurance seeking). Important and perhaps central cognitions to health anxiety were identified. Health anxious individuals regarded themselves to be at greater risk for disease overall, and attached greater accuracy to health related information. Extending the cognitive-behavioural theory, health anxiety was found to be associated with decreased usage of positive somatic monitoring of symptoms, suggesting health anxiety may be associated with a failure to engage in protective strategies. Health anxiety did not result in cognitive or behavioural avoidance of illness information. Clinical implications and future directions for research are described.

Health anxiety moderates the effects of distraction versus attention to pain

Little is known about the relationship between health anxiety and chronic pain. The present study explored whether individual differences in health anxiety would influence the response of chronic pain patients to physical therapy. Furthermore, the interaction of health anxiety with coping strategy usage (distraction versus attention) was studied. Participants were 81 chronic pain patients who were interviewed and completed measures of pain, anxiety and cognition following an active physiotherapy session in which they either: (1) attended to physical sensations; (2) distracted from physical sensations or (3) completed the session as usual. Health anxious, compared to non-health anxious, individuals worried more about their health and injury during the session and attended to and catastrophically misinterpreted sensations more frequently. A complex interaction between health anxiety and coping strategy emerged. Among health anxious patients, attention to sensations resulted in lower anxiety and pain than did distraction. It appears as though attention had a short-term anxiety reducing effect for health anxious patients. Among non-health anxious patients, attention resulted in greater worry about health than distraction. Clinical and theoretical implications are discussed.

Factor structure and psychometric properties of the Pain Anxiety Symptoms Scale-20 in a community physiotherapy clinic sample.

The PASS‐20 was developed to assess pain‐related anxiety among a variety of pain populations. This measure was constructed by extracting 20 items from its 40‐item parent measure (PASS). Initial studies of the PASS‐20 suggest that the psychometric properties have been preserved. The purpose of the present study extended this research and explored the factor structure of the PASS‐20, and its reliability and validity in a sample of pain patients receiving treatment in a community physiotherapy clinic. Patients with current pain (n=201) were asked to complete a battery of self‐report measures related to the experience of pain on two separate occasions (3‐month interval). Results of principal components analyses suggested that a 4‐factor solution representing fear of pain, escape‐avoidance, physiological symptoms, and cognitive symptoms of anxiety provided the best fit to these data. Results also showed that the total and subscale scores of the PASS‐20 have good reliability (internal consistency, test—retest) and validity (construct) correlating greater with other conceptually similar measures than distinct constructs. These results suggest that this measure has good utility for both clinical and research applications. Directions for future evaluation are also discussed.

Using facial expressions to assess musculoskeletal pain in older persons.

Past research examined measures of pain among seniors who were experiencing movement‐related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain‐related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duratio of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post‐surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapists supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.

The Short Health Anxiety Inventory: A systematic review and meta-analysis

INTRODUCTION The Short Health Anxiety Inventory (SHAI) measures health anxiety in medical and non-medical contexts. OBJECTIVE To review the literature pertaining to the psychometric properties of the SHAI in non-clinical, clinical, and medical samples. Meta-analysis was also conducted to examine the strength of associations between the SHAI and other constructs. METHODS Direct search of digital databases for papers that cited the original SHAI publication. RESULTS Seventy-eight papers were identified, with 42 providing relevant information. The SHAI has acceptable Cronbachs alpha scores, strong construct validity, and is sensitive to treatment. Discrepancies have been observed between the findings of factor analytic studies, largely as a result of varying methods used. Overall, there appears to be greatest support for the original two factors, with one factor assessing health anxiety and one factor assessing negative consequences of illness. As expected, individuals with hypochondriasis score higher as compared to non-clinical samples. The strongest association was observed between the SHAI and other measures of health anxiety, followed by measures related to health anxiety vulnerability, and then general anxiety and worry. CONCLUSIONS The SHAI is a psychometrically sound tool for assessing health anxiety across samples. Future studies are needed, however, to assess test-retest reliability, incremental validity, and cut-off scores as well as use of the SHAI among diverse samples.

Validation of the Chronic Pain Coping Inventory

The Chronic Pain Coping Inventory (CPCI; Jensen, M.P., Turner, J.A., Romano, J.M. and Strom, S.E., The Chronic Pain Coping Inventory: development and preliminary validation, Pain, 60 (1995) 203-216) is a recently developed questionnaire comprising eight main subscales that measure coping strategies that are frequently targeted for change in interdisciplinary pain treatment programs. Preliminary research, carried out by the developers of the CPCI, supports the reliability and validity of the scale. The purpose of the present study was to further examine the validity of the CPCI independently. In the present study, 210 patients were administered the CPCI, along with the Coping Strategies Questionnaire (CSQ; Rosenstiel, A.K. and Keefe, F.J., The use of coping strategies in low back pain patients: relationship to patient characteristics and current adjustment, Pain, 17 (1983) 33-44; Riley III, J.L. and Robinson, M.E., CSQ: five factors or fiction? Clin. J. Pain, 13 (1997) 156-162), and the Multidimensional Pain Inventory (MPI; Kerns, R.D., Turk, D.C. and Rudy, T.E.. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356) as part of a pre-admission screening. Principal components analysis with oblique rotation was performed on the 64 main CPCI scale items. An eight-factor solution was identified as most appropriate. The original subscales were generally supported, however, some modifications to scoring of subscales were suggested. As a second step in the study, the relationship between the modified CPCI subscales and the CSQ subscales were examined and their relative ability to predict concurrent adjustment to pain (MPI subscales) was assessed. Results indicated that CPCI subscales tap coping constructs that are conceptually different than the CSQ subscales. Several CPCI subscales were also found to be significantly and uniquely related to measures of concurrent adjustment, even after taking CSQ subscales and demographic and pain-related variables into account. These results suggest the CPCI is a valuable tool, above and beyond established coping measures, in the clinical assessment and research of pain. Directions for future research are discussed.

Anxiety sensitivity and disabling chronic health conditions: State of the art and future directions.

Anxiety sensitivity (AS) is a construct that denotes an individual difference in fear of anxiety. Most research into the AS construct has focused on its association with panic attacks, panic disorder and several other psychiatric disorders. There has been growing interest recently in AS as an important factor in the maintenance and exacerbation of morbidity associated with some disabling chronic health conditions (e.g. gastrointestinal dysfunction, asthma, vestibular dysfunction and chronic pain). The purposes of this paper are (a) to provide a brief overview of the theoretical framework within which the AS and chronic health condition literature can be synthesized, (b) to review the existing literature regarding AS and chronic health conditions and (c) to offer recommendations for assessment and treatment. Theoretically and practically relevant directions for future investigation are provided throughout the review.

Exploratory and confirmatory factor analytic investigations of the Illness Attitudes Scale in a nonclinical sample

The Illness Attitudes Scale (IAS) assesses fears, beliefs and attitudes associated with hypochondriasis [Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger Publishers.]. Recent factor analytic investigations of the IAS in non-clinical samples have suggested a number of different factor solutions. In study 1, we used principal components analysis with both orthogonal and oblique rotation to better explore the structure of this measure. Using a random selection of 390 participants from a larger pool of 780, a five-factor solution was identified: (1) fear of illness, death, disease and pain, (2) effects of symptoms, (3) treatment experiences, (4) disease conviction and (5) health habits. In study 2, confirmatory factor analysis (CFA) of responses from the remaining 390 students evaluated: (a) a single-factor model, (b) Kellners original nine-factor model, (c) a four-factor model proposed by Ferguson and Daniel [Ferguson, E. & Daniel, E. (1995). The Illness Attitudes Scale (IAS): a psychometric evaluation on a nonclinical population. Personality and Individual Differences, 18, 463-469.], (d) a different four-factor model proposed by Stewart and Watt [Stewart, S. H. & Watt, M. C. (1998). A psychometric investigation of the Illness Attitudes Scale (IAS) in a nonclinical young adult sample. Submitted for publication.] and (e) the five-factor model derived in study 1. Of these models, greatest support was obtained for our five-factor model. However, it was also clear that this model could be improved. Based on the results of the CFA, as well as previous research and theoretical considerations, we tested a revised model in which the health habits factor was deleted. Analysis of the revised model showed that it received the greatest support and could be conceptualized as either four distinct factors or as hierarchical in nature, with four lower-order factors loading on a single higher-order factor. Future directions for research as well as suggestions for scoring and using the IAS with nonclinical samples are discussed.

Judging pain in infants: behavioural, contextual, and developmental determinants

&NA; Caretakers intuitively use various sources of evidence when judging infant pain, but the relative importance of salient cues has received little attention. This investigation examined the predictive significance for judgements of painful discomfort in preterm and full‐term neonates of behavioural (facial activity and body movement), contextual (invasiveness of the procedure), and developmental (gestational age) information. Judges viewed videotapes showing infants varying in the foregoing characteristics undergoing heel incisions for routine blood sampling purposes. Findings indicated all but the contextual information contributed uniquely to judgements of pain, with facial activity accounting for the most unique variance (35%), followed by bodily activity and gestational age, each accounting for 3% and 1% of the judgmental variance, respectively. Generally, 71% of the variance in ratings of pain could be predicted using facial activity alone, compared to 30% of the variance using bodily activity alone, 19% by relying on context alone, and 8% by referring to gestational age alone. Noteworthy was the tendency to judge early preterm infants to be experiencing less pain even though they were subjected to the same invasive procedure as the older infants. This finding also runs counter to evidence from developmental neurobiology which indicates that preterm newborns may be hypersensitive to invasive procedures.

Measures of anxiety: is there a difference in their ability to predict functioning at three-month follow-up among pain patients?

Independent investigators have found that pain is related to health anxiety, trait anxiety, pain‐related anxiety, and anxiety sensitivity. To date, the relationship among these anxiety‐related constructs has not been studied directly and little is known about their relative ability to predict adjustment to pain over time. This paper presents longitudinal data from measures given to 227 musculoskeletal pain patients. Patients were asked at the time of their first visit (T1) to a physiotherapy clinic to complete a questionnaire package including measures of these different forms of anxiety as well as pain severity, disability, negative affect, and perceived control. Approximately 3 months later (T2), 50% of patients responded to these same questionnaires. Results showed that correlations among the anxiety measures at T1 ranged from 0.35 to 0.56. Using multiple regression analyses, measures of T1 anxiety were each examined for their ability to predict unique variance in disability, negative affect, and perceptions of control measured at T1 and T2. At T1, after controlling for pain severity and other measures of anxiety, pain‐related anxiety uniquely predicted both disability and negative affect, trait anxiety uniquely predicted negative affect and perceptions of control, and anxiety sensitivity uniquely predicted negative affect. At T2, after controlling for pain severity, other measures of anxiety and each respective measure of functioning at T1, health anxiety uniquely predicted disability and negative affect, although anxiety sensitivity also uniquely contributed to the prediction of negative affect. It is concluded that the importance of various forms of anxiety is dependent on the timeframe and outcome examined. Clinical implications of the findings as well as directions for future research are discussed.