Patricia Furer

Death Anxiety: A Cognitive-Behavioral Approach

Over the years, there has been a considerable amount of psychological research focused on death anxiety. However, little attention has been given to clinical aspects of this problem. This paper focuses on a practical approach to assessment and treatment of death anxiety for the clinician. We discuss situations where it is wise to evaluate death anxiety and provide questions to address this topic in a sensitive manner. Death anxiety is clearly a central feature of health anxiety and may also play a significant role in other anxiety disorders. While there is very little specific research on treatment of fear of death, research on the anxiety disorders in general and health anxiety in particular has facilitated the development of an approach we have found useful in treating death anxiety. The main components of this treatment include exposure to feared themes related to death, reduction of safety behaviors, cognitive reappraisal, increased focus on life goals and life enjoyment, and relapse prevention.

Treatment preference in hypochondriasis.

Promising cognitive-behavioral and medication treatments for hypochondriasis are in the early stages of evaluation. Little is known about the treatment preferences and opinions of individuals seeking help for this problem. In this exploratory study, 23 volunteers from the community with a DSM-IV diagnosis of hypochondriasis were recruited through a newspaper advertisement. Participants were presented with a survey which included balanced descriptions of both a medication and a cognitive-behavioral treatment for intense illness concerns (hypochondriasis). The brief descriptions of the treatments discussed the time commitment required as well as the major advantages and disadvantages of each. Results showed that, relative to medication treatment, cognitive-behavioral treatment was predicted to be more effective in both the short and long terms and was rated as more acceptable. Psychological treatment was indicated as the first choice by 74% of respondents, medication by 4%, and 22% indicated an equal preference. Forty-eight percent of respondents would only accept the psychological treatment.

HYPOCHONDRIACAL CONCERNS AND SOMATIZATION IN PANIC DISORDER

To clarify the relationship between panic disorder and the symptoms of hypochondriasis and somatization, we evaluated these symptoms and diagnoses in patients attending an Anxiety Disorders Clinic. Structured clinical interviews, self‐report measures, and symptom diaries were used to assess 21 patients with panic disorder, 23 patients with social phobia, and 22 control subjects with no psychiatric disorders. Ten of the patients with panic disorder (48%) also met DSM‐IV criteria for hypochondriasis, whereas only one of the patients with social phobia and none of the healthy control subjects met the criteria for this diagnosis. None of the participants met DSM‐IV criteria for somatization disorder, even though both anxiety groups reported high levels of somatic symptoms. The panic disorder group reported higher levels of fear about illness and disease conviction and endorsed more somatic symptoms than did the other groups. A higher proportion of panic disorder patients reported previously diagnosed medical conditions (48%) as compared with patients with social phobia (17%) or healthy control subjects (14%). The panic disorder patients with DSM‐IV hypochondriasis obtained higher scores on measures of hypochondriacal concerns, somatization, blood–injury phobia, and general anxiety and distress than did the panic disorder patients without hypochondriasis. The results suggest a strong association between panic disorder and hypochondriasis. Depression and Anxiety 6:78–85, 1997.

Treatment of Hypochondriasis with Exposure

Cognitive-behavioral therapy has been shown to be an effective treatment for hypochondriasis. An important element of most of the empirically validated CBT protocols for this problem is exposure. Various approaches to exposure may be useful including in vivo exposure to health and death-related situations, interoceptive exposure to feared bodily symptoms, and imaginal exposure to symptoms and feared illnesses that are difficult to reproduce in real life. Strategies for enhancing the effectiveness of exposure, such as response prevention, cognitive reappraisal, and acceptance, are also discussed. Practical suggestions for implementation of exposure with this population are provided.

Interoceptive Exposure in the Treatment of Health Anxiety and Hypochondriasis

The experience of health anxiety is seen in a range of different anxiety and somatoform disorders. Bodily sensations are often cues for anxiety or emotional distress in persons with problems with health anxiety and hypochondriasis. In treating these problems, there are advantages to including interoceptive exposure (IE) as a component of treatment. We explore the frequency of problems with bodily symptoms in community and clinical populations, the assessment of physical symptoms, and the theoretical rationale for the use of IE in treatment. This exposure strategy involves deliberately and repeatedly producing feared bodily sensations. Given that some of the anxiety-producing symptoms commonly seen in health anxiety are difficult to produce voluntarily, we also have clients use strategies involving deliberately focusing on existing bothersome sensations and using imaginal techniques to simulate body sensations. The goal of IE is to help the individual to be more accepting of and less distressed by the uncomfortable bodily symptoms. The integration of this approach with other treatment components for health anxiety, such as cognitive reappraisal, exposure to feared thoughts and behaviors, and reducing avoidance, is emphasized. Detailed guidelines for the application of IE with health anxiety are provided.

Confirmatory Factor Analysis of the Childhood Illness Attitude Scales

A series of confirmatory factor analyses (CFA) were performed on responses from 195 school-age children to the Childhood Illness Attitude Scales (CIAS; Wright & Asmundson, 2003) Three-, modified 3-, 4- and 4-factor higher-order models were examined. Items originally comprising the treatment experience factor in the 4-factor higher-order model were removed resulting in a revised 3-factor model that best fit the data. Initial construct validity was established by observing moderate correlations between revised CIAS subscale and total scores and measures of anxiety-related constructs, and somatization. Suggested revisions to the CIAS warrant future examination. Implications for clinical practice are discussed.

Evaluating the quality of perinatal anxiety information available online

The Internet is an easily accessible source of information for women experiencing anxiety in pregnancy and/or postpartum to use when seeking health information. However, the Internet has several drawbacks, including inaccurate content that may be perceived as being accurate, non-biased, and evidence-based. Prior research indicates that anxiety and postpartum mental health websites have poor quality in terms of describing treatment options. There is a lack of research and knowledge in the area of perinatal anxiety, and an absence of research evaluating perinatal anxiety websites. The purpose of this study was to evaluate the quality of information regarding perinatal anxiety available on the Internet. Websites concerning perinatal anxiety were selected using the Google search engine. Each website was evaluated based on quality of health information, website usability, and readability. The 20 websites included in this study had low to moderate quality scores based on the DISCERN tool. There were no associations found between website order and website quality, or between website readability and website quality. Many websites had high PEMAT scores for the understandability section, which included content, style, and layout of information; however, most did not use visual aids to enhance comprehension. Most websites had low actionability scores, suggesting that information may not be useful in describing what actions may be taken to manage perinatal anxiety. This study highlights the need for high-quality websites concerning perinatal anxiety that are easy to navigate and provide the public with evidence-based information.