Self-focused attention and the relationship between hypochondriac symptomatology and the perception of hypothetical symptoms of influenza
Bachelor Thesis 2008 47 Pages
This study tested the hypothesis that people scoring highly on hypocondriasis (measured by the Illness Attitude Scale; Kellner, 1986), perceive it most intensely (measured by the Revised Illness Perception Questionnaire; Moss-Morris et al., 2002) when they receive a self-focused attention manipulation. One hundred and seventy students either received a treatment increasing their self-focused attention, or a neutral treatment. After that, they were exposed to a health-message about influenza. It was found that the hypothesis was not supported. Unexpectedly, self-focused people scoring high on hypocondriasis perceived the hypothetical influenza illness less intensively on some dimensions, whilst low scorers perceived symptoms more intensively under high self-focus. It is suggested that self-focused attention might activate a defence mechanism in people scoring high on hypocondriasis, where symptoms are perceived less intensely. In conclusion, this research should be replicated in order to verify the unexpected findings.
The term ‘hypochondriasis’ can be traced back to the Greek physician Hippocrates (460 - 370 BC) who used it to describe a specific part of the costal arch. Nowadays, the idea has found its way into everyday speech. Someone who is hypochondriac has unsubstantiated beliefs of suffering from a severe medical disease (Hiller, Rief & Fichter, 2002). Hypochondriasis is classed as a somatoform disorder (American Psychiatric Association, 1994). Davison, Neale & Kring (2004) defined hypochondriasis as a “preoccupation with fears of having a serious illness” (p. 174), e.g. cancer or cardiovascular conditions. In this connexion, Bleichhardt & Hiller (2006) conceived hypochondriasis as distinct from the broader concept of ‘health anxiety’, which refers to more generalised concerns about health that are not necessarily dependent upon symptom perception and interpretation (Asmundson, Taylor, Sevgur & Cox, 2001a). Moreover, hypochondriasis can be regarded as a specific and extreme form of health anxiety. However, the issue of conceptualisation of hypochondriasis, health anxiety and its association with somatoform disorders and anxiety disorders, is still subject to an unsolved debate in the literature (Asmundson, Taylor, Wright & Cox, 2001b).
Incidence is the number of new cases of a disorder that appear in a defined population during a certain period of time. Asmundson et al. (2001a) reported the incidence of hypochondriasis being in a range from 3.4 - 13.5% in various clinical populations using criteria of Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) or International Classification of Diseases, Tenth Revision (ICD-10). There are no incidence studies in non-clinical populations. Therefore, nothing can be said about the incidence of hypochondriasis in a non- clinical population, as a cross-sectional generalisation of findings from a clinical population is not permissible. On the other hand, prevalence denotes the proportion of a defined population affected by a disorder at a given time. The prevalence of hypochondriasis has a range from 0.8 - 8.5% in clinical populations, whereupon diagnostic criteria were used (Asmundson et al., 2001a; Greeven et al., 2007). Prevalence estimates are quoted from 0.02 - 7.7% outside of clinical populations (Noyes, Happel & Yagla, 1999; Bleichhardt & Hiller, 2006). In conclusion, the epidemiology of hypochondriasis is not clarified sufficiently yet. Moreover, surveys with non-clinical samples are still barely existent to this day - which identifies an immense gap in previous research (Bleichhardt & Hiller, 2007).
It is clear from the preceding paragraph that hypochondriasis occurs in clinical as well as in non-clinical populations when diagnostic criteria were used. Notwithstanding, most members of the general non-clinical population have an experience of hypochondriasis to a certain degree, too. Asmundson et al. (2001a) pointed out that numerous people are often worried and concerned about their health. However, those people do not meet the full diagnostic criteria of hypochondriasis. There is some evidence suggesting that sub-clinical hypochondriasis is prevailing in the general population to a large extent. For example, Martin & Jacobi (2006) reported an overall prevalence rate of 10.35% for subthreshold hypochondriasis in Germany. Bleichhardt & Hiller (2007) reported a prevalence rate of six percent for severe health anxiety in Germany. This corroborates that the study of hypochondriasis in a non-clinical population is of tremendous importance. Creed & Barsky (2004) demonstrated that the prevalence of hypochondriasis in a non-clinical sample was too low to examine, meeting full criteria of Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV). Martin & Jacobi (2006) suggested that hypochondriasis in its sub-clinical form is still problematic for both - the experience and the behaviour of individuals. Concerning this matter, the next section is discussing implications of hypochondriasis.
Bleichhardt & Hiller (2005) reported that hypochondriacs exhibit abnormal illness behaviour. Both wrong cognitive conclusions and unrealistic assessments about having a serious medical condition result in repeated attempts to obtain reassurance. This means, hypochondriacs turn to a doctor frequently in order to make sure that they do not have a suspected disease. In this connexion, MacLeod, Haynes & Sensky (1998) postulated that these patients tend to have more somatic attributions about bodily sensations. The foregoing implies not only negative consequences for the individual, but also for the national health care provider. Conradt, Cavanagh, Franklin & Rief (2006) suggested that even at sub-clinical degrees of severity, the economic impact of hypochondriasis is substantial. Hypochondriac worries significantly intensify health care utilisation: It has been estimated for the USA that $20 billion per year are spent on those patients, which represents ten to twenty percent of the US health care budget (Demopulos et al., 1996). It is obvious that aforementioned numbers predominantly date from non-clinical patients as the prevalence of full- developed hypochondriasis is seldom (Martin & Jacobi, 2006). In the light of the tremendous costs, this in turn demonstrates how important research into sub-clinical hypochondriasis is.
Hypocondriasis and Attention
Two explanatory models of hypochondriasis exist in the literature. One of them is Salkovskis’s & Warwick’s (1986, 1989, 1990) ‘Cognitive-Behavioural Model’ (cited in Salkovskis & Warwick, 2001; Owens, Asmundson, Hadjistavropoulos & Owens, 2004). The model postulates that individuals high in hypochondriasis attend to disease-related information in a biased manner, because of their selective attention. This results in increased concentration on information that gives the impression of having an illness and decreased perception of evidence indicating good health; the model was verified by Owens et al. (2004). This cognitive perspective underpins that hypochondriasis has got an attentional problem, inherent in the idea of the ‘attentional bias’. Furthermore, the Cognitive-Behavioural Model also talks about the ‘interpretive bias’. This means that hypochondriacs will attend to illness-related information in a biased style (Hadjistavropoulos, Craig & Hadjistavropoulos, 1998). That is to say, hypochondriacs selectively attend to information that seems to confirm the belief of having an illness and to neglect opposed information (Owens et al., 2004). Therefore, the Cognitive-Behavioural Model underpins that hypochondriasis has got an attentional problem.
The other relevant model in this context is Barsky’s & colleagues’ (1979, 1991) concept of ‘Somatosensory Amplification’ (cited in McClure & Lilienfeld, 2001; Stewart & Watt, 2001; Bleichhardt & Hiller, 2005; van den Heuvel et al., 2005). By this, one understands a perception style, which is specific for hypochondriasis. Concerned people tend to observe bodily sensations and interpret those in a catastrophic way (Rief, Hiller & Margraf, 1998). While attending more intensely to the perceived bodily symptoms, it is assumed that catastrophic interpretations of paresthesia symptoms are stabilised as signs of a severe illness in a vicious circle.
Somatosensory Amplification as a psycho-physiological explanation of
hypochondriasis also supports its strong relationship with attention. The idea becomes more plausible when pointing at the fact that increased attention amplifies bodily sensations in this concept. It is well known that aforementioned theories - with attention as their core - are used as a theoretical framework in the treatment for hypochondriasis (e.g. Salkovskis, Warwick & Deale, 2003; Avia & Ruiz, 2005).
Kirmayer & Looper (2006) noticed that increased attention to bodily sensations plays an important role in hypochondriasis. For example, the authors Lautenbacher, Pauli, Zaudig & Birmbaumer (1996) reported that attentional distraction reduces the perceived intensity of pain for both hypochondriacs and normals. This suggests an association between hypochondriasis and attention. Support for this idea also comes from Hiller et al. (2002) who hypothesised that health anxiety, which can be seen as non-clinical hypochondriasis, is linked to selective attention. A study by Haenen, Schmidt, Kroeze & van den Hout (1996) showed an association between hypochondriasis and attention. They found that hypochondriacs had higher levels of symptom reporting; and that attention instructions towards bodily sensations added significantly to this effect. Another article by Steptoe & Noll (1997) described a significant correlation between hypochondriasis and the accuracy of perception of sweat gland activity. This may show that hypochondriasis and attention are connected, because attention intensifies perception of bodily symptoms (Brown, Poliakoff & Kirkman, 2007). However, Steptoe & Noll (1997) did not directly measure attention in their research.
The aforementioned studies, however, have a number of limitations. Firstly, experimenter effects could have influenced attentional manipulation as it was administered verbally (Lautenbacher et al., 1996; Haenen et al., 1996). And secondly, none of the aforementioned studies has proved whether attention might be an aetiological factor for the outcome of hypochondriasis in a normal population. Therefore, studies with a clear defined concept of attention as well as a neutral administration of the attentional manipulation are needed. Moreover, there is a pressing need for studies, which can give insights into the causal factors of hypochondriac behaviour. The next paragraph discusses the theoretical background of an attentional approach to hypochondriasis.
The following section is reviewing evidence from therapy, which indicates the important impact of self-focused attention on hypochondriasis (Duval & Wicklund, 1972; cited in Silvia & Abele, 2002; Silvia & Eichstaedt, 2004). Self-focused attention means that people focus attention on the self and, as a consequence, monitor their thoughts and actions in relation to their personal standards (Duval & Silvia, 2001; cited in Silvia & Eichstaedt, 2004). The meta-cognitive skill of self-awareness has important implications for social, cognitive and clinical issues (Spurr & Stopa, 2002) - and will be examined in terms of hypochondriasis.
On an integrative (psycho-physiological and cognitive) perspective it is believed from therapeutic experiences that hypochondriacs tend to have a heightened body-focused attention (Papageorgiou & Wells, 1998; Wells, 2007), which leads to hyper-vigilance towards certain regions of the body (Bleichhardt & Hiller, 2005; Olatunji, Deacon, Abramowitz & Valentiner, 2007). Therapy reduces this ‘attentional bias’ theorised in the Cognitive-Behavioural Model, e.g. by shifting the patient’s attention away from the perceived threat, which reduces hypochondriac behaviour (Williams, 2004). This shows that self-focused attention has an impact on hypochondriasis, because through this manipulation, attention is no longer concentrated on the self, but rather on the environment; and people are less identified with the perceived illness. As Williams (2004) suggested, attentional processes may operate beyond conscious awareness - and self-focused attention takes this complexity into consideration. On the other hand, a phenomenon called ‘Cognitive Attentional Syndrome’ is used as a theoretical framework in therapy of hypochondriasis (Wells, 2007). Excessive self-focused attention is a surface marker of the activation of this syndrome, increasing body- focused attention. The ‘Attentional Training Technique’ (Papageorgiou & Wells, 1998; Wells, 2007) improves hypochondriac behaviour by exercises involving selective attention, divided attention, and attention switching. Zvolensky & Forsyth (2002; Olatunji et al., 2007) outlined, participants who have greater physiological concerns (hypochondriasis) also report higher levels of internal attentional focus (self- focused attention), describing a possible reason why the Attentional Training Technique works. All this suggests that self-focused attention has a major impact on hypochondriasis. However, limitations of previously discussed studies is that it is not explained into detail how self-focused attention affects hypochondriasis; self-focused attention is not conceptualised explicitly in the therapeutic context of the debated articles albeit the concept is assumed implicitly. Therefore, it is essential to fill this gap in the literature with a study, which justifies and explains the usage of self- focused attention.
Study Rationale, Aims and Hypotheses
In order to understand clinical syndromes such as hypochondriasis, Kirmayer & Sartorius (2007) concluded that the methods and the knowledge of experimental cognitive and social psychology are needed. The present research project takes their suggestion into account since self-focused attention is conceptualised. Here, a self- focused attention manipulation (Silvia & Abele, 2002; Silvia & Eichstaedt, 2004) is used in order to see whether the interpretation of symptomatology is influenced by self-focused attention. In other words, does a self-focused attention manipulation affect people’s cognitions about their perceived symptoms? Additionally, the present study is attempting to understand to what extent self-focused attention can be classified as an aetiological factor of hypochondriasis. Moreover, the present study fills the gap that surveys about hypochondriasis with non-clinical samples are seldom (Bleichhardt & Hiller, 2007), as the present study was conducted with a student sample. Furthermore, this research demonstrates that sub-clinical hypochondriasis is existent in the general population, which has not been shown before. Moreover, this study comes up with a novel approach to operationalise hypochondriac responses: hypothetical symptomology. People are requested to imagine they had a serious illness; and then rate how serious they perceive the imagined condition, which is typical for hypochondriacs. Another innovation of this study is the use of the ‘Revised Illness Perception Questionnaire’ (IPQ-R) by Moss-Morris et al. (2002) to examine the ‘interpretative bias’.
The objective of this study is to test the idea that heightened symptomology and interpretation of symptomology in hypochondriasis partly results from self-focused attention. Hypochondriasis is measured with the ‘Illness Attitude Scale’ (IAS), which was originally invented by Kellner (1986; cited in Rief et al., 1998; Steward & Watt, 2000; Crössmann & Pauli, 2006). Self-focused attention is manipulated as suggested in Silvia & Abele (2002) and Silvia & Eichstaedt (2004) via a self-description task: Participants in the experimental condition are given a treatment that significantly increases their self-focused attention and consequently their self-awareness - in contrast to participants in the control condition. More precisely, participants in the experimental condition are asked to describe ways in which they differ from others, i.e. from their family, friends and people in general. On the other hand, participants in the control condition are asked neutral questions, e.g. “please describe the last time you went out to eat”. After this, all participants are presented a health related message pertaining to influenza. Subsequently, participants are asked to imagine that they had influenza. The hypochondriac response is measured with the IPQ-R (Moss-Morris et al., 2002).
The aims of this study are therefore firstly, to manipulate self-focused attention to see whether this results in heightened hypochondriac symptomology. Secondly, hypothetical symptomology can be used to examine hypochondriac responses. Thirdly, the IPQ-R can also be used to operationalise imagined illness beliefs (e.g. symptom reporting) for imagined medical conditions (hypochondriasis). Fourthly, the IPQ-R can be used to examine ‘interpretative biases’ in hypochondriasis. Fifthly, subclinical hypochondriasis prevails in non-clinical populations to a certain extent. And finally, this study is attempting to give a first insight into self-focused attention as a potential aetiological factor of hypochondriasis.
Considering the available evidence it is hypothesised that
1. Participants, who perceive more hypochondriac symptomatology, interpret it in a more negative way than participants who perceive less hypochondriac symptomatology.
2. Participants, who receive a self-focused attention manipulation, interpret hypochondriac symptomatology more intensely than participants who receive a neutral treatment.
3. Participants, who report more hypochondriac symptomatology, perceive it most intensely when they receive a self-focused attention manipulation.
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- Self-focused attention Self-focussed attention Hypochondria Hypochondriasis Influenza Hypothetical Symptoms Illness Attitude Scale IAS Illness Perception Questionnaire IPQ-R interpretative bias