Cognitive Biase in Illness Anxiety Disorder: Attentional Bias, Interpretation Bias, and Memory Bias

Authors
Saemeh Khalili-Torghabeh
Javad Salehi Fadardi
Zohreh Sepehri Shamloo
Seyed Kazem Rasoulzadeh Tabatabai
Ferdowsi University of Mashhad
Abstract
Cognitive biases are influential factors in explaining illness anxiety disorder, and understanding the existing biases in this disorder can contribute to more effective treatments. This study was conducted to examine the biases of attention, interpretation, and memory in individuals with and without illness anxiety disorder. The sample consisted of 142 participants who voluntarily participated in the research from across the country. In this study, differences in information processing between the two groups were assessed using the Health Anxiety Questionnaire, Beck Depression Inventory, and computer-based tasks measuring attention bias, interpretation, and memory. The data obtained from the research were analyzed using independent t-tests and analysis of covariance (ANCOVA) with the statistical software SPSS 26.The results showed that individuals with illness anxiety disorder had a greater tendency to focus on threatening cues compared to those without the disorder and interpreted ambiguous health-related information more negatively. However, no significant differences were observed between the two groups regarding positive interpretation bias. Additionally, individuals with illness anxiety recalled disease-related information more effectively. The findings indicate that individuals with illness anxiety display biases in attention, negative interpretation, and memory concerning health-related information. This research emphasizes the importance of identifying and targeting these biases in psychological treatments and suggests employing intervention methods such as cognitive bias modification to directly affect these biases due to their role in the formation and persistence of illness anxiety.
Keywords
illness anxiety
attentional bias
Interpretation bias
Memory bias
Abramowitz, J. S., & Braddock, A. (2008). Psychological treatment of health anxiety and hypochondriasis: A biopsychosocial approach. Hogrefe Publishing GmbH.
Abramowitz, J. S., & Moore, E. L. (2007). An experimental analysis of hypochondriasis. Behaviour research and Therapy, 45(3), 413-424.
Akhavan, M., Pourghane, P., Karimi, Z., & Mohseni, F. (2019). Frequency of Hypochondria disorder in operating room personnel of educational hospitals of Guilan University of Medical Sciences. Shenakht Journal of Psychology and Psychiatry, 6(3), 83-92.
Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Automatic and strategic processes. Behaviour research and Therapy, 35(1), 49-58.
Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck depression inventory–II. Psychological Assessment.
Bobevski, I., Clarke, D. M., & Meadows, G. (2016). Health anxiety and its relationship to disability and service use: findings from a large epidemiological survey. Psychosomatic medicine, 78(1), 13-25.
Cisler, J. M., & Koster, E. H. (2010). Mechanisms of attentional biases towards threat in anxiety disorders: An integrative review. Clinical psychology review, 30(2), 203-216.
Cohen, J. (1992). Statistical power analysis. Current directions in psychological science, 1(3), 98-101.
Dehghani, M. (2010). Construction and validation of pictorial «dot probe» task using emotional faces as stimuli. International Journal of Behavioral Sciences, 3(4), 265-270.
Dehghani, M., Khatibi, A., & Pour Etemad, H. R. (2009). Construction and validation of pictorial dot probe task using emotional faces as stimuli. 10(3), 265-270.
Delshad, A., Sanati, Z., Hatamikia, M., & Mohammadi, S. (2014). Hypochondriasis and related factors in population of 20-50 years old in Gonabad city. Journal of Internal Medicine Today, 19(5), 17-22. [Persian].
Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. (2022). American Psychiatric Association Publishing.
Du, X., Witthöft, M., Zhang, T., Shi, C., & Ren, Z. (2023). Interpretation bias in health anxiety: A systematic review and meta-analysis–CORRIGENDUM. Psychological medicine, 1-1.
Everaert, J., Duyck, W., & Koster, E. H. (2014). Attention, interpretation, and memory biases in subclinical depression: a proof-of-principle test of the combined cognitive biases hypothesis. Emotion, 14(2), 331.
Everaert, J., & Koster, E. H. (2020). The interplay among attention, interpretation, and memory biases in depression: Revisiting the combined cognitive bias hypothesis. Cognitive biases in health and psychiatric disorders, 193-213.
Everaert, J., Koster, E. H., & Derakshan, N. (2012). The combined cognitive bias hypothesis in depression. Clinical psychology review, 32(5), 413-424.
Everaert, J., Tierens, M., Uzieblo, K., & Koster, E. H. (2013). The indirect effect of attention bias on memory via interpretation bias: Evidence for the combined cognitive bias hypothesis in subclinical depression. Cognition & emotion, 27(8), 1450-1459.
Fata, L., Birashk, B., ATEF, V. M., & Dabson, K. (2005). Meaning assignment structures/schema, emotional states and cognitive processing of emotional information: comparing two conceptual frameworks. [persian].
Fergus, T. A., & Asmundson, G. J. G. (2019). Chapter Four - Cognitive and Behavioral Mechanisms of Health Anxiety. In E. Hedman-Lagerlöf (Ed.), The Clinician's Guide to Treating Health Anxiety (pp. 43-64). Academic Press.
Gasemnejad, S. M., Jaallalmanesh, S., Rasady, M., & Mahmoudi, M. (2011). Association study of anxiety and hypochondriasis in student of Islamic Azad University, Lahijan medical branch in 2008. Medical Sciences Journal, 21(3), 222-226. [Persian].
Gehrt, T. B., Macoveanu, J., Bailey, C. J., Fisher, P. M., Pallesen, K. J., & Frostholm, L. (2023). Resting-state connectivity and neural response to emotional images in patients with severe health anxiety: An fMRI study. Journal of Affective Disorders, 324, 370-378.
Gehrt, T. B., Niziurski, J. A., Frostholm, L., & Berntsen, D. (2019). Encoding and retrieval biases for health-related scenes in patients with severe health anxiety. Memory, 27(8), 1110-1121.
Hamadani, M. (2019). Monotheistic approach of the prophet Mohammad to illness. Journal of Religion and Health, 6(2), 62-72.
Hirsch, C. R., Clark, D. M., & Mathews, A. (2006). Imagery and interpretations in social phobia: Support for the combined cognitive biases hypothesis. Behavior therapy, 37(3), 223-236.
Hitchcock, P. B., & Mathews, A. (1992). Interpretation of bodily symptoms in hypochondriasis. Behaviour research and Therapy, 30(3), 223-234.
Hoffmann, D., Rask, C. U., & Frostholm, L. (2019). Acceptance and commitment therapy for health anxiety. In The clinician's guide to treating health anxiety (pp. 123-142). Elsevier.
Ironside, M., Browning, M., Ansari, T. L., Harvey, C. J., Sekyi-Djan, M. N., Bishop, S. J., Harmer, C. J., & O’Shea, J. (2017). Prefrontal cortex regulates amygdala response to threat in trait anxiety. BioRxiv, 215699.
Jasper, F., & Witthöft, M. (2011). Health anxiety and attentional bias: The time course of vigilance and avoidance in light of pictorial illness information. Journal of Anxiety Disorders, 25(8), 1131-1138.
Kenwood, M. M., Kalin, N. H., & Barbas, H. (2022). The prefrontal cortex, pathological anxiety, and anxiety disorders. Neuropsychopharmacology, 47(1), 260-275.
Khalili-Torghabeh, S., Shamloo, Z. S., Tabatabaei, K. R., & Fadardi, J. S. Development and Standardization of a Computerized Task for the Assessment of Implicit Interpretation Bias Among Patients with Illness Anxiety Disorder. Available at SSRN 4556535.
Kobori, O., Okita, M., Shiraishi, T., Hasegawa, T., & Iyo, M. (2014). Health anxiety and healthcare costs in Japanese individuals: an Internet survey. Health Psychology and Behavioral Medicine: an Open Access Journal, 2(1), 833-840.
Kocjan, J. (2016). Short Health Anxiety Inventory (SHAI)-Polish version: Evaluation of psychometric properties and factor structure. Archives of Psychiatry and Psychotherapy, 3, 68-78.
Kosic, A., Lindholm, P., Järvholm, K., Hedman-Lagerlöf, E., & Axelsson, E. (2020). Three decades of increase in health anxiety: Systematic review and meta-analysis of birth cohort changes in university student samples from 1985 to 2017. Journal of Anxiety Disorders, 71, 102208.
Köteles, F., & Simor, P. (2014). Modern health worries: Somatosensory amplification, health anxiety and well-being: A cross-sectional study. European Journal of Mental Health, 9(1), 20.
Leung, C. J., Yiend, J., Trotta, A., & Lee, T. M. (2022). The combined cognitive bias hypothesis in anxiety: A systematic review and meta-analysis. Journal of anxiety disorders, 89, 102575.
MacLeod, C., & Mathews, A. (1988). Anxiety and the allocation of attention to threat. The Quarterly Journal of Experimental Psychology Section A, 40(4), 653-670.
MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emotional disorders. Journal of abnormal psychology, 95(1), 15.
Mahdavifar, N., Mohammadian, M., Kalan Farmanfarma, K., Khosrorad, R., Dizavandi, A. R., Sani, F. V., & Salehiniya, H. (2023). Evaluation of the prevalence of illness anxiety disorder following the COVID‐19 pandemic in Iran and its related factors: a cross‐sectional study. Health science reports, 6(1), e943.
Mathôt, S., & March, J. (2022). Conducting linguistic experiments online with OpenSesame and OSWeb. Language Learning, 72(4), 1017-1048.
Mathôt, S., Schreij, D., & Theeuwes, J. (2012). OpenSesame: An open-source, graphical experiment builder for the social sciences. Behavior research methods, 44, 314-324.
Mier, D., Bailer, J., Ofer, J., Kerstner, T., Zamoscik, V., Rist, F., Witthöft, M., & Diener, C. (2017). Neural correlates of an attentional bias to health-threatening stimuli in individuals with pathological health anxiety. Journal of Psychiatry and Neuroscience, 42(3), 200-209.
Milstein, G., Palitsky, R., & Cuevas, A. (2020). The religion variable in community health promotion and illness prevention. Journal of Prevention & Intervention in the Community, 48(1), 1-6.
Moghaddaszadeh Bazzaz, M., Fadardi, J. S., Kareshki, H., & Parkinson, J. (2017). The role of cognitive processing on dieters` success or fail. Cognitive Psychology Journal, 5(2), 1-10. [Presian].
Mousavi, S. M., yazdani Rad, s., Sadeghian, M., Abbasi, M., & Jahadi naeini, M. (2021). Relationship between Resilience and Hypochondriasis due to COVID-19: A Case Study in an Occupational Environment [Research Article]. Journal of Occupational Hygiene Engineering, 7(4), 35-43. https://doi.org/10.52547/johe.7.4.35
Norbye, A. D., Abelsen, B., Førde, O. H., & Ringberg, U. (2022). Health anxiety is an important driver of healthcare use. BMC Health Services Research, 22(1), 138.
Ojalehto, H. J., Abramowitz, J. S., Hellberg, S. N., Butcher, M. W., & Buchholz, J. L. (2021). Predicting COVID-19-related anxiety: The role of obsessive-compulsive symptom dimensions, anxiety sensitivity, and body vigilance. Journal of anxiety disorders, 83, 102460.
Olatunji, B. O., Deacon, B. J., Abramowitz, J. S., & Valentiner, D. P. (2007). Body vigilance in nonclinical and anxiety disorder samples: structure, correlates, and prediction of health concerns. Behavior therapy, 38(4), 392-401.
Orchard, F., Pass, L., & Reynolds, S. (2016). ‘It was all my fault’; negative interpretation bias in depressed adolescents. Journal of abnormal child psychology, 44, 991-998.
panahi, s., asghari moghadam, m. a., shaeeri, m. r., & eghtedar nejhad, s. (2010). Psychometric properties of a Persian version of the short form of health anxiety inventory in non-clinical Iranian populations. Quarterly of Educational Measurement, 1(2), 21-46. [Presian].
Rachman, S. (2012). Health anxiety disorders: A cognitive construal. Behaviour research and therapy, 50(7-8), 502-512.
Rask, C. U., Duholm, C. S., Poulsen, C. M., Rimvall, M. K., & Wright, K. D. (2024). Annual Research Review: Health anxiety in children and adolescents—developmental aspects and cross‐generational influences. Journal of Child Psychology and Psychiatry, 65(4), 413-430.
Salkovskis, P. M., Rimes, K. A., Warwick, H., & Clark, D. (2002). The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological medicine, 32(5), 843-853.
Salkovskis, P. M., & Warwick, H. (2001). Meaning, misinterpretations, and medicine: A cognitive-behavioral approach to understanding health anxiety and hypochondriasis.
Salkovskis, P. M., & Warwick, H. M. (1986). Morbid preoccupations, health anxiety and reassurance: a cognitive-behavioural approach to hypochondriasis. Behaviour research and Therapy, 24(5), 597-602.
Salmani, R., Kazemi, H., Sarbakhsh, P., & Mousazadeh, Y. (2023). Hypochondriasis and self-medication among medical sciences students during the COVID-19 pandemic: A descriptive cross-sectional study in Northwestern Iran. Work (Reading, Mass.).
Shi, C., Taylor, S., Witthöft, M., Du, X., Zhang, T., Lu, S., & Ren, Z. (2022). Attentional bias toward health-threat in health anxiety: a systematic review and three-level meta-analysis. Psychological medicine, 52(4), 604-613.
Stefan, S., Zorila, A., & Brie, E. (2020). General threat and health-related attention biases in illness anxiety disorder. A brief research report. Cognition and Emotion, 34(3), 604-613.
Talaei, A., & Fayazi bordbar, m. (2009). Hypochondrias in Resident Students of Mashhad University of Medical Sciences [Research]. Journal of Ilam University of Medical Sciences, 17(1), 8-18. [persian]. http://sjimu.medilam.ac.ir/article-1-87-en.html
Taylor, S., Asmundson, G. J., & Hyprochondria. (2004). Treating health anxiety: A cognitive-behavioral approach (Vol. 494). Guilford Press New York.
Ting, R. S.-K., Aw Yong, Y.-Y., Tan, M.-M., & Yap, C.-K. (2021). Cultural responses to COVID-19 pandemic: Religions, illness perception, and perceived stress. Frontiers in psychology, 12, 634863.
Tyrer, P., Cooper, S., Tyrer, H., Wang, D., & Bassett, P. (2019). Increase in the prevalence of health anxiety in medical clinics: possible cyberchondria. International Journal of Social Psychiatry, 65(7-8), 566-569.
Valadez, E. A., Pine, D. S., Fox, N. A., & Bar-Haim, Y. (2022). Attentional biases in human anxiety. Neuroscience & Biobehavioral Reviews, 142, 104917.
Vrijsen, J. N., Dainer-Best, J., Witcraft, S. M., Papini, S., Hertel, P., Beevers, C. G., Becker, E. S., & Smits, J. A. (2019). Effect of cognitive bias modification-memory on depressive symptoms and autobiographical memory bias: Two independent studies in high-ruminating and dysphoric samples. Cognition and Emotion, 33(2), 288-304.
Wang, Y.-P., & Gorenstein, C. (2013). Psychometric properties of the Beck Depression Inventory-II: a comprehensive review. Brazilian Journal of Psychiatry, 35, 416-431.
Weck, F., Neng, J. M., Richtberg, S., & Stangier, U. (2012). Dysfunctional beliefs about symptoms and illness in patients with hypochondriasis. Psychosomatics, 53(2), 148-154.
Witthöft, M., Kerstner, T., Ofer, J., Mier, D., Rist, F., Diener, C., & Bailer, J. (2016). Cognitive biases in pathological health anxiety: The contribution of attention, memory, and evaluation processes. Clinical Psychological Science, 4(3), 464-479.
Yan, Z., Witthöft, M., Bailer, J., Diener, C., & Mier, D. (2019). Scary symptoms? Functional magnetic resonance imaging evidence for symptom interpretation bias in pathological health anxiety. European archives of psychiatry and clinical neuroscience, 269, 195-207.
Zare, H., & Alipor, A. (2017). Construction and validation of computer program of attention bias modification treatment for social anxiety disorder. Advances in Cognitive Science, 19(2), 19-29.