HEALTH ANXIETY AMONG OLDER ADULTS

HEALTH ANXIETY AMONG OLDER ADULTS: ASSESSING THE EFFICACY OF

COGNITIVE BEHAVIOURAL TREATMENT

A Thesis

Submitted to the Faculty of Graduate Studies and Research

In Partial Fulfillment of the Requirements

for the Degree of

Doctor of Philosophy

in Clinical Psychology

University of Regina

by

Michelle D. Bourgault-Fagnou

Regina, Saskatchewan

December 2010

Copyright 2010: M. D. Bourgault-Fagnou

HEALTH ANXIETY AMONG OLDER ADULTS: ASSESSING THE EFFICACY OF

COGNITIVE BEHAVIOURAL TREATMENT

A Thesis

Submitted to the Faculty of Graduate Studies and Research

In Partial Fulfillment of the Requirements

for the Degree of

Doctor of Philosophy

in Clinical Psychology

University of Regina

by

Michelle D. Bourgault-Fagnou

Regina, Saskatchewan

December 2010

Copyright 2010: M. D. Bourgault-Fagnou

1+1

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1*1 Library and Archives Canada

Published Heritage Branch

395 Wellington Street OttawaONK1A0N4 Canada

Bibliotheque et Archives Canada

Direction du Patrimoine de I'edition

395, rue Wellington Ottawa ON K1A 0N4 Canada

Your file Votre reference ISBN: 978-0-494-79975-8 Our We Notre reference ISBN: 978-0-494-79975-8

NOTICE: AVIS:

The author has granted a nonexclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or noncommercial purposes, in microform, paper, electronic and/or any other formats.

L'auteur a accorde une licence non exclusive permettant a la Bibliotheque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par telecommunication ou par I'lnternet, preter, distribuer et vendre des theses partout dans le monde, a des fins commerciales ou autres, sur support microforme, papier, electronique et/ou autres formats.

The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission.

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In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis.

Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these.

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Canada

UNIVERSITY OF REGINA

FACULTY OF GRADUATE STUDIES AND RESEARCH

SUPERVISORY AND EXAMINING COMMITTEE

Ms. Michelle Denise Bourgault-Fagnou, candidate for the degree of Doctor of Philosophy in Psychology, has presented a thesis titled, Health Anxiety Among Older Adults: Assessing The Efficacy Of Cognitive Behavioural Treatment, in an oral examination held on December 15, 2010. The following committee members have found the thesis acceptable in form and content, and that the candidate demonstrated satisfactory knowledge of the subject material.

External Examiner: **Dr. Patricia Furer, Faculty of Medicine, University of Manitoba

Supervisor: Dr. Heather Hadjistavropoulos, Department of Psychology

Committee Member: Dr. Gordon Asmundson, Department of Psychology

Committee Member: *Dr. Thomas Hadjistavropoulos, Department of Psychology

Committee Member: Dr. Ron Martin, Faculty of Education

Chair of Defense: Dr. Ian Germani, Department of History

*Not present at defense **Via Video Conference

UNIVERSITY OF REGINA

FACULTY OF GRADUATE STUDIES AND RESEARCH

SUPERVISORY AND EXAMINING COMMITTEE

Ms. Michelle Denise Bourgault-Fagnou, candidate for the degree of Doctor of Philosophy in Psychology, has presented a thesis titled, Health Anxiety Among Older Adults: Assessing The Efficacy Of Cognitive Behavioural Treatment, in an oral examination held on December 15, 2010. The following committee members have found the thesis acceptable in form and content, and that the candidate demonstrated satisfactory knowledge of the subject material.

External Examiner: *Dr. Patricia Furer, Faculty of Medicine, University of Manitoba

Supervisor: Dr. Heather Hadjistavropoulos, Department of Psychology

Committee Member: Dr. Gordon Asmundson, Department of Psychology

Committee Member: "Dr. Thomas Hadjistavropoulos, Department of Psychology

Committee Member: Dr. Ron Martin, Faculty of Education

Chair of Defense: Dr. Ian Germani, Department of History

*Not present at defense **Via Video Conference

ABTRACT

The purpose of this research was to assess the effectiveness of a six-session enhanced

cognitive behavioural therapy (ECBT) program for health anxiety in older adults (i.e.,

learning and memory aids), and to examine whether the program fostered the therapeutic

alliance and motivation for psychotherapy as compared to a standard cognitive

behavioural therapy (SCBT) program and wait-list control (WLC) condition. In Study 1,

57 community dwelling seniors 60 years of age and over with elevated levels of health

anxiety were randomly assigned to six weeks of SCBT, ECBT, or WLC. At pre-

treatment, post-treatment, and three-month follow-up, participants completed

questionnaires on health anxiety and its dimensions, and measures of anxiety sensitivity,

state and trait anxiety, depression, pain, and health-related quality of life. Participants

also completed measures of therapeutic alliance and motivation for psychotherapy.

Participants were asked to complete open-ended questions at pre-treatment on the nature

of health anxiety and at post-treatment on the experience of therapy. In Study 2, a control

group of 57 community participants matched with the older adult group on sex and

Whiteley Index (WI) score was used as a comparison on measures of health anxiety and

its dimensions. In Study 1, the results of the mixed factorial ANCOVAs indicated

participants in the SCBT and ECBT groups showed significantly lower levels of health

anxiety on the WI, with significant reductions in both group on subscales measuring

disease fear and bodily preoccupation. There was also a significant improvement in the

SCBT group on the physical component of health-related quality of life when compared

to the WLC group. Using paired samples t-tests to examine pre- to post-treatment scores,

ii

ABTRACT

The purpose of this research was to assess the effectiveness of a six-session enhanced

cognitive behavioural therapy (ECBT) program for health anxiety in older adults (i.e.,

learning and memory aids), and to examine whether the program fostered the therapeutic

alliance and motivation for psychotherapy as compared to a standard cognitive

behavioural therapy (SCBT) program and wait-list control (WLC) condition. In Study 1,

57 community dwelling seniors 60 years of age and over with elevated levels of health

anxiety were randomly assigned to six weeks of SCBT, ECBT, or WLC. At pre-

treatment, post-treatment, and three-month follow-up, participants completed

questionnaires on health anxiety and its dimensions, and measures of anxiety sensitivity,

state and trait anxiety, depression, pain, and health-related quality of life. Participants

also completed measures of therapeutic alliance and motivation for psychotherapy.

Participants were asked to complete open-ended questions at pre-treatment on the nature

of health anxiety and at post-treatment on the experience of therapy. In Study 2, a control

group of 57 community participants matched with the older adult group on sex and

Whiteley Index (WI) score was used as a comparison on measures of health anxiety and

its dimensions. In Study 1, the results of the mixed factorial ANCOVAs indicated

participants in the SCBT and ECBT groups showed significantly lower levels of health

anxiety on the WI, with significant reductions in both group on subscales measuring

disease fear and bodily preoccupation. There was also a significant improvement in the

SCBT group on the physical component of health-related quality of life when compared

to the WLC group. Using paired samples t-tests to examine pre- to post-treatment scores,

ii

participants in the SCBT group demonstrated significant improvements on all three

measures of health anxiety, state and trait anxiety, depression, and both physical and

mental components of health-related quality of life; participants in the ECBT group

demonstrated significant improvements on two measures of health anxiety (WI, Short

Health Anxiety Inventory), hypochondriacal somatic symptoms, anxiety sensitivity, and

depression. Only one measure showed improvement in the WLC group. On both the

ANCOVAs and paired samples t-tests, from post-treatment to follow-up, treatment gains

were maintained and improvements were seen on select measures. These findings, along

with findings from examination of clinically significant change, maintenance of gains at

follow-up, and post-treatment responses to open-ended questions, suggested both SCBT

and ECBT were effective in improving scores on measures. Qualitative analysis of open-

ended responses at pre-treatment identified five themes describing the development of

health anxiety in older adults including Anxiety as Genetic, Anxiety as a Learned

Response, Vulnerability to Illness and Disease, Awfulness of Illness, Inability to Cope,

and Inadequacy of Physicians/Medical Care. In Study 2, the younger adult group was

significantly higher than the older adult group on all measures with the exception of a

subscale measuring disease fear/phobia. Although the results from Study 1 were mixed,

overall, the findings indicated that cognitive behavioural therapy is effective for reducing

aspects of health anxiety in older adults. The results contributed to the understanding of

therapeutic factors and the cognitive behavioural model of health anxiety in older adults.

Additional study implications, contributions, limitations, and future directions are

discussed.

iii

participants in the SCBT group demonstrated significant improvements on all three

measures of health anxiety, state and trait anxiety, depression, and both physical and

mental components of health-related quality of life; participants in the ECBT group

demonstrated significant improvements on two measures of health anxiety (WI, Short

Health Anxiety Inventory), hypochondriacal somatic symptoms, anxiety sensitivity, and

depression. Only one measure showed improvement in the WLC group. On both the

ANCOVAs and paired samples t-tests, from post-treatment to follow-up, treatment gains

were maintained and improvements were seen on select measures. These findings, along

with findings from examination of clinically significant change, maintenance of gains at

follow-up, and post-treatment responses to open-ended questions, suggested both SCBT

and ECBT were effective in improving scores on measures. Qualitative analysis of open-

ended responses at pre-treatment identified five themes describing the development of

health anxiety in older adults including Anxiety as Genetic, Anxiety as a Learned

Response, Vulnerability to Illness and Disease, Awfulness of Illness, Inability to Cope,

and Inadequacy of Physicians/Medical Care. In Study 2, the younger adult group was

significantly higher than the older adult group on all measures with the exception of a

subscale measuring disease fear/phobia. Although the results from Study 1 were mixed,

overall, the findings indicated that cognitive behavioural therapy is effective for reducing

aspects of health anxiety in older adults. The results contributed to the understanding of

therapeutic factors and the cognitive behavioural model of health anxiety in older adults.

Additional study implications, contributions, limitations, and future directions are

discussed.

iii

ACKNOWLEDGEMENTS

Many people contributed their time and knowledge to this dissertation and provided

valuable advice and assistance throughout the process. First and foremost, I would like to

extend my deepest gratitude to my supervisor, Dr. Heather Hadjistavropoulos. She has

been an ongoing source of support and guidance through all the phases of this project.

Her expertise, assistance, and feedback were essential to the completion of this study. I

am very grateful to have such an inspiring and supportive advisor who always took the

time to provide encouragement and guidance. I would also like to thank the members of

my committee, Drs. Gordon Asmundson, Thomas Hadjistavropoulos, and Ron Martin,

for their time, expertise, support, and efficiency. All three have contributed substantially

and my dissertation benefited as a result. I would especially like to thank my participants

who contributed their time and information to this study. Without their help, this

dissertation would not have been possible. Also, a special thank you to Amy Janzen,

Amanda Lints-Martindale, and Jocelyne Leclerc for their assistance in data collection. I

would like to thank the Centre on Aging and Health at the University of Regina for

providing me with SGI Graduate Fellowships in Aging and Health to assist in the funding

of my program. I would also like to acknowledge the Faculty of Graduate Studies and

Research for providing teaching assistantships and scholarships to help fund my studies

and research.

iv

ACKNOWLEDGEMENTS

Many people contributed their time and knowledge to this dissertation and provided

valuable advice and assistance throughout the process. First and foremost, I would like to

extend my deepest gratitude to my supervisor, Dr. Heather Hadjistavropoulos. She has

been an ongoing source of support and guidance through all the phases of this project.

Her expertise, assistance, and feedback were essential to the completion of this study. I

am very grateful to have such an inspiring and supportive advisor who always took the

time to provide encouragement and guidance. I would also like to thank the members of

my committee, Drs. Gordon Asmundson, Thomas Hadjistavropoulos, and Ron Martin,

for their time, expertise, support, and efficiency. All three have contributed substantially

and my dissertation benefited as a result. I would especially like to thank my participants

who contributed their time and information to this study. Without their help, this

dissertation would not have been possible. Also, a special thank you to Amy Janzen,

Amanda Lints-Martindale, and Jocelyne Leclerc for their assistance in data collection. I

would like to thank the Centre on Aging and Health at the University of Regina for

providing me with SGI Graduate Fellowships in Aging and Health to assist in the funding

of my program. I would also like to acknowledge the Faculty of Graduate Studies and

Research for providing teaching assistantships and scholarships to help fund my studies

and research.

iv

DEDICATION

I would like to thank my parents, Gerry and Louise, for their unwavering support during

the course of this work. Without their help, I could not have completed this dissertation.

A well-deserved thank you also goes to my siblings and my friends for their help,

empathy, and support. Most importantly, I would like to acknowledge my husband,

Andre, for the many sacrifices he made in order to support me in completing this work.

Thank you for your endless patience, understanding, and support.

v

DEDICATION

I would like to thank my parents, Gerry and Louise, for their unwavering support during

the course of this work. Without their help, I could not have completed this dissertation.

A well-deserved thank you also goes to my siblings and my friends for their help,

empathy, and support. Most importantly, I would like to acknowledge my husband,

Andre, for the many sacrifices he made in order to support me in completing this work.

Thank you for your endless patience, understanding, and support.

v

TABLE OF CONTENTS

ABSTRACT ii

ACKNOWLEDGEMENTS iv

DEDICATION v

TABLE OF CONTENTS vi

LIST OF TABLES x

LIST OF FIGURES xiii

LIST OF APPENDICES xvi

1. INTRODUCTION 1

1.1 Overview 1

1.2 Health Anxiety Versus Hypochondriasis 4

1.3 Features Associated with Health Anxiety 9

1.3.1 Cognitive and Somatic Features 9

1.3.2 Behaviours Associated with Health Anxiety 10

1.3.3 Patient-Physician Relationships 12

1.4 Theoretical Approach to Health Anxiety 14

1.4.1 Misinterpretations and Maintenance of Health Anxiety 16

1.5 Health Anxiety Among Seniors 26

1.5.1 How Does the Cognitive Behavioural Model of Health 29

Anxiety Apply to Older Adults?

1.6 Other Forms of Anxiety Among Seniors 30

1.6.1 Symptoms of Anxiety: Trait and State Anxiety 30

vi

TABLE OF CONTENTS

ABSTRACT ii

ACKNOWLEDGEMENTS iv

DEDICATION v

TABLE OF CONTENTS vi

LIST OF TABLES x

LIST OF FIGURES xiii

LIST OF APPENDICES xvi

1. INTRODUCTION 1

1.1 Overview 1

1.2 Health Anxiety Versus Hypochondriasis 4

1.3 Features Associated with Health Anxiety 9

1.3.1 Cognitive and Somatic Features 9

1.3.2 Behaviours Associated with Health Anxiety 10

1.3.3 Patient-Physician Relationships 12

1.4 Theoretical Approach to Health Anxiety 14

1.4.1 Misinterpretations and Maintenance of Health Anxiety 16

1.5 Health Anxiety Among Seniors 26

1.5.1 How Does the Cognitive Behavioural Model of Health 29

Anxiety Apply to Older Adults?

1.6 Other Forms of Anxiety Among Seniors 30

1.6.1 Symptoms of Anxiety: Trait and State Anxiety 30

vi

1.6.2 Anxiety Sensitivity 32

1.7 Depression and Its Relationship to Health Anxiety in Seniors 33

1.8 Treatment Issues 34

1.8.1 Treatment of Health Anxiety 34

1.8.2 Enhancing CBT for Use with Older Adults 44

1.8.3 Reason Why CBT May Be Effective with Older Adults 46

1.8.4 Fostering the Therapeutic Alliance 47

1.8.5 Motivation in Psychotherapy 50

1.9 Research Problem and Purpose 52

1.10 Hypotheses 55

1.10.1 Hypotheses: Study 1 55


2. METHOD 57

2.1 Study 1 57

2.1.1 Participants 57

2.1.2 Measures 60

2.1.2.1 Primary Outcome Measures 64

2.1.2.2 Secondary Outcome Measures 75

2.1.2.3 Therapy Programs: Measures of the

Therapeutic Relationship and

Motivation for Psychotherapy 79

2.1.3 Standard Cognitive Behavioural Therapy (SCBT) and

vii

1.6.2 Anxiety Sensitivity 32

1.7 Depression and Its Relationship to Health Anxiety in Seniors 33

1.8 Treatment Issues 34

1.8.1 Treatment of Health Anxiety 34

1.8.2 Enhancing CBT for Use with Older Adults 44

1.8.3 Reason Why CBT May Be Effective with Older Adults 46

1.8.4 Fostering the Therapeutic Alliance 47

1.8.5 Motivation in Psychotherapy 50

1.9 Research Problem and Purpose 52

1.10 Hypotheses 55



2. METHOD 57

2.1 Study 1 57

2.1.1 Participants 57

2.1.2 Measures 60

2.1.2.1 Primary Outcome Measures 64


2.1.2.3 Therapy Programs: Measures of the

Therapeutic Relationship and

Motivation for Psychotherapy 79

2.1.3 Standard Cognitive Behavioural Therapy (SCBT) and

vii

Enhanced Cognitive Behavioural Therapy (ECBT) 81

2.1.4 Procedure 83

2.1.5 Design and Analyses 85

2.1.5.1 Analyses 85

2.1.5.2 Preparation of the Data for Analysis 87

2.1.5.3 Qualitative Data Analysis 88

2.2 Study 2 90

2.2.1 Participants and Procedure 90

2.2.2 Preparation of the Data for Analysis 91

3. RESULTS 95

3 1 Study 1 95

3.1.1 Preliminary Analyses 95

3.1.2 Testing Hypothesis 1 105

3.1.2.1 Subscale Comparisons 110


3.1.3 Testing Hypotheses 2 and 3: Stability of Improvements 120

3.1.4 Hypothesis 4 and 5 — Therapeutic Alliance and Motivation

for Psychotherapy 124

3.1.5 Process and Significance of Change 127

3.1.5.1 Treatment Specific Change 127

3.1.5.2 Clinically Significant Change 137

3.1.6 Supplementary Analyses 141

viii

Enhanced Cognitive Behavioural Therapy (ECBT) 81

2.1.4 Procedure 83

2.1.5 Design and Analyses 85

2.1.5.1 Analyses 85

2.1.5.2 Preparation of the Data for Analysis 87

2.1.5.3 Qualitative Data Analysis 88

2.2 Study 2 90

2.2.1 Participants and Procedure 90

2.2.2 Preparation of the Data for Analysis 91

3. RESULTS 95

3.1 Study 1 95

3.1.1 Preliminary Analyses 95

3.1.2 Testing Hypothesis 1 105

3.1.2.1 Subscale Comparisons 110


3.1.3 Testing Hypotheses 2 and 3: Stability of Improvements 120

3.1.4 Hypothesis 4 and 5 - Therapeutic Alliance and Motivation

for Psychotherapy 124

3.1.5 Process and Significance of Change 127

3.1.5.1 Treatment Specific Change 127

3.1.5.2 Clinically Significant Change 137

3.1.6 Supplementary Analyses 141

viii

3.1.6.1 Relationship Between Health Anxiety and the Therapeutic

Relationship and Motivation for Psychotherapy at Post-

Treatment 141

3.1.6.2 Analysis of Change in the WLC Group 146

3.1.7 Results of the Qualitative Analysis 155

3.1.7.1 Pre-Treatment Responses 155

3.1.7.2 Post-Treatment Responses 163

3.2 Study 2 173

3.2.1 Comparison on Anxiety Measures 173

4. DISCUSSION 176

4.1 Assessment of Hypotheses 177

4.2 Qualitative Analysis Examining Experience of Health Anxiety 190

Among Seniors

4.3 Comparison of Older and Younger Adults on Health Anxiety 192

4.4 Contributions 195

4.5 Limitations 196

4.6 Future Directions 199

4.7 Conclusion 201

5. REFERENCES 202

ix

3.1.6.1 Relationship Between Health Anxiety and the Therapeutic

Relationship and Motivation for Psychotherapy at Post-

Treatment 141

3.1.6.2 Analysis of Change in the WLC Group 146

3.1.7 Results of the Qualitative Analysis 155

3.1.7.1 Pre-Treatment Responses 155

3.1.7.2 Post-Treatment Responses 163

3.2 Study 2 173

3.2.1 Comparison on Anxiety Measures 173

4. DISCUSSION 176

4.1 Assessment of Hypotheses 177

4.2 Qualitative Analysis Examining Experience of Health Anxiety 190

Among Seniors

4.3 Comparison of Older and Younger Adults on Health Anxiety 192

4.4 Contributions 195

4.5 Limitations 196

4.6 Future Directions 199

4.7 Conclusion 201

5. REFERENCES 202

ix

LIST OF TABLES

Table

1. Background Characteristics by Group 59

2. Comparisons of Background Characteristics between Groups 61

3. Summary of Participants' Health Conditions by Group 62

4. Demographic Information and Scale Scores for Matched Participants 92

5. Summary of Participants' Health Conditions by Group 93

6. Means and Standard Deviations for Primary and Secondary Outcome

Measures 96

7. Means and Standard Deviations for WI, SHAI, and IAS Subscales 99

8. Means and Standard Deviations for WAI and NML-2 Subscales 101

9. Correlations Between Measures at Pre-Treatment 103

10. Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Primary

Outcome Measures 106

11. Comparisons from Pre- to Post-Treatment for Primary Dependent

Variables 109

12. Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for WI, SHAI, and

IAS Subscales 111

13. Comparisons from Pre- to Post-Treatment for WI Subscale 113

14. Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Secondary


LIST OF TABLES

Table

1. Background Characteristics by Group 59

2. Comparisons of Background Characteristics between Groups 61

3. Summary of Participants'Health Conditions by Group 62

4. Demographic Information and Scale Scores for Matched Participants 92

5. Summary of Participants'Health Conditions by Group 93

6. Means and Standard Deviations for Primary and Secondary Outcome

Measures 96

7. Means and Standard Deviations for WI, SHAI, and IAS Subscales 99

8. Means and Standard Deviations for WAI and NML-2 Subscales 101

9. Correlations Between Measures at Pre-Treatment 103

10. Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Primary


11. Comparisons from Pre- to Post-Treatment for Primary Dependent

Variables 109

12. Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for WI, SHAI, and

IAS Subscales 111

13. Comparisons from Pre- to Post-Treatment for WI Subscale 113

14. Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Secondary


15. Comparisons from Pre- to Post-Treatment for Secondary Outcome

Measures 119

16. Comparisons from Post-Treatment to Follow-Up for the Primary


17. Comparisons from Post-Treatment to Follow-Up for the WI, SHAI,

and IAS Subscales 122

18. Comparisons from Post-Treatment to Follow-Up for the Secondary

Outcome Measures. 123

19. Mixed-Factor 3 (Time) x 2 (Treatment) ANCOVAs for WAI and

NML-2 Subscales 125

20. Comparisons from Session 1, Session 3, and Session 6 on the WAI-

Goals Subscale 126

21. Paired T-Tests for Each Primary Outcome Measure 129

22. Paired T-Tests for Each Subscale on WAI, SHAI, and IAS 131

23. Paired T-Tests for Each Secondary Outcome Measure 134

24. Correlations Between the WAI and NML-2 and the Health Anxiety

Measures Change Scores in the SCBT Group 142


Measures Change Scores in the ECBT Group 144

26. WLC Group Analyses at Time 1, 2, and 3 for the Primary Outcome

Measures 147

27. WLC Group Analyses at Time 1, 2, and 3 for the Secondary Outcome

xi

15. Comparisons from Pre- to Post-Treatment for Secondary Outcome

Measures 119

16. Comparisons from Post-Treatment to Follow-Up for the Primary


17. Comparisons from Post-Treatment to Follow-Up for the WI, SHAI,

and IAS Subscales 122

18. Comparisons from Post-Treatment to Follow-Up for the Secondary

Outcome Measures. 123

19. Mixed-Factor 3 (Time) x 2 (Treatment) ANCOVAs for WAI and

NML-2 Subscales 125

20. Comparisons from Session 1, Session 3, and Session 6 on the WAI-

Goals Subscale 126

21. Paired T-Tests for Each Primary Outcome Measure 129

22. Paired T-Tests for Each Subscale on WAI, SHAI, and IAS 131

23. Paired T-Tests for Each Secondary Outcome Measure 134


Measures Change Scores in the SCBT Group 142


Measures Change Scores in the ECBT Group 144

26. WLC Group Analyses at Time 1, 2, and 3 for the Primary Outcome

Measures 147

27. WLC Group Analyses at Time 1, 2, and 3 for the Secondary Outcome

xi

Measures 149

28. WLC Group Analyses at Time 1, 2, and 3 for the WI and SHAI

Subscales 151

29. Themes and Sub-Themes of the Development of Health Anxiety in

Seniors 156

30. Themes and Sub-Themes of Older Adults' Experiences and

Perceptions of Psychological Treatment for Health Anxiety 165

31. Scale Scores for Matched Participants 174

xii

Measures 149

28. WLC Group Analyses at Time 1, 2, and 3 for the WI and SHAI

Subscales 151

29. Themes and Sub-Themes of the Development of Health Anxiety in

Seniors 156

30. Themes and Sub-Themes of Older Adults' Experiences and

Perceptions of Psychological Treatment for Health Anxiety 165

31. Scale Scores for Matched Participants 174

xii

LIST OF FIGURES

Figure

1. Cognitive behavioural model of the development of health anxiety 15

2. Relationship between enhancements, factors affecting seniors in

therapy, and outcome in psychotherapy 54

3. Flow of participants through the treatments 86

4. Mean WI scores by treatment condition at pre-treatment and post-

treatment 108

5. Mean WI — Disease Fear/Phobia scores by treatment condition at pre-

treatment and post-treatment 115

6. Mean SF-12-PCS scores by treatment condition at pre-treatment and

post-treatment 118

7. Mean WAI - Goal scores by treatment condition at Session 1, Session

2, and Session 3 128

8. Proportion of participants in each treatment condition who

demonstrated clinically significant change, according to Jacobson and

Truax's (1992) definition, on the WI 139

9. Proportion of participants in each treatment condition who had WI

scores below 8 at post-treatment 141

10. Model of the development of health anxiety in older adults 157

11. Model of older adults' experiences and perceptions of psychological

treatment for health anxiety 164

LIST OF FIGURES

Figure

1. Cognitive behavioural model of the development of health anxiety 15

2. Relationship between enhancements, factors affecting seniors in

therapy, and outcome in psychotherapy 54

3. Flow of participants through the treatments 86

4. Mean WI scores by treatment condition at pre-treatment and post-

treatment 108

5. Mean WI - Disease Fear/Phobia scores by treatment condition at pre-

treatment and post-treatment 115

6. Mean SF-12-PCS scores by treatment condition at pre-treatment and

post-treatment 118

7. Mean WAI - Goal scores by treatment condition at Session 1, Session

2, and Session 3 128

8. Proportion of participants in each treatment condition who

demonstrated clinically significant change, according to Jacobson and

Truax's (1992) definition, on the WI 139

9. Proportion of participants in each treatment condition who had WI

scores below 8 at post-treatment 141

10. Model of the development of health anxiety in older adults 157

11. Model of older adults' experiences and perceptions of psychological

treatment for health anxiety 164

xiii

LIST OF APPENDICES

Appendix

A Recruitment Poster 233

B Information Sheet and Consent Form 234

C Outline of Videos 238

D University of Regina Research Ethics Board Approval 245

E Questionnaires 246

F Online Classified Notice 269

G Information Sheet and Consent Form for Online Study 270

xiv

LIST OF APPENDICES

Appendix

A Recruitment Poster 233

B Information Sheet and Consent Form 234

C Outline of Videos 238

D University of Regina Research Ethics Board Approval 245

E Questionnaires 246

F Online Classified Notice 269

G Information Sheet and Consent Form for Online Study 270

xiv

1. INTRODUCTION

1.1 Overview

Factors associated with aging, such as higher rates of medical illness, physical

frailty, and a heightened sense of mortality, may contribute to excessive preoccupation

with health-related issues among older adults (Snyder & Stanley, 2001). In fact, 10% to

15% of seniors exhibit a marked concern about their health (Ables, 1997). This is

problematic as heightened levels of anxiety among older adults have been found to be

associated with increased depression (Jeste, Hays, & Steffens, 2006), increased morbidity

(Ostir & Goodwin, 2006), chronic health conditions (Diala & Muntaner, 2003), and

markedly higher health care costs (Simon, Ormel, VonKoff, & Barlow, 1995). The

negative implications of anxiety demonstrate the importance of performing additional

research on the nature of anxiety as well as methods for reducing anxiety in the older

adult population.

The nature of anxiety can be best understood by examining both what it is and

what it is not. The construct of anxiety can be differentiated from the construct of fear,

for example. There is a great deal of evidence to suggest that anxiety and fear reactions

differ psychologically and physically (Barlow, Brown, & Craske, 1994). Fear can be

described as an immediate emotional reaction to an imminent threat or danger and it is

characterized by strong escapist action tendencies and activation of the autonomic

nervous system (e.g., increased heart rate and blood pressure; Barlow et al., 1994). The

term anxiety, on the other hand, is used to describe a future-oriented mood-state

characterized by marked negative affect, bodily symptoms of tension, and apprehension

1

1. INTRODUCTION

1.1 Overview

Factors associated with aging, such as higher rates of medical illness, physical

frailty, and a heightened sense of mortality, may contribute to excessive preoccupation

with health-related issues among older adults (Snyder & Stanley, 2001). In fact, 10% to

15% of seniors exhibit a marked concern about their health (Abies, 1997). This is

problematic as heightened levels of anxiety among older adults have been found to be

associated with increased depression (Jeste, Hays, & Steffens, 2006), increased morbidity

(Ostir & Goodwin, 2006), chronic health conditions (Diala & Muntaner, 2003), and

markedly higher health care costs (Simon, Ormel, VonKoff, & Barlow, 1995). The

negative implications of anxiety demonstrate the importance of performing additional

research on the nature of anxiety as well as methods for reducing anxiety in the older

adult population.

The nature of anxiety can be best understood by examining both what it is and

what it is not. The construct of anxiety can be differentiated from the construct of fear,

for example. There is a great deal of evidence to suggest that anxiety and fear reactions

differ psychologically and physically (Barlow, Brown, & Craske, 1994). Fear can be

described as an immediate emotional reaction to an imminent threat or danger and it is

characterized by strong escapist action tendencies and activation of the autonomic

nervous system (e.g., increased heart rate and blood pressure; Barlow et al., 1994). The

term anxiety, on the other hand, is used to describe a future-oriented mood-state

characterized by marked negative affect, bodily symptoms of tension, and apprehension

1

about the future because one cannot predict or control upcoming events (Barlow, 1988).

The focus of this research will be on anxiety regarding health among the older adult

population.

Several specific types of anxiety have been identified in the literature, such as

anxiety disorders, and trait, state, and health anxiety. Research focused on the prevalence

of specific anxiety disorders suggests they are a significant issue for older adults. Most

recently, Byers, Yaffe, Covinsky, Friedman, and Bruce (2010) examined nationally

representative estimates of age-specific 12-month prevalence rates of the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR; American

Psychiatric Association [APA], 2000) anxiety disorders among 2575 community-

dwelling adults 55 years of age and older in the National Comorbidity Survey Replication

(NCS-R) in the United States. Using the Composite International Diagnostic Interview

(CIDI; Kessler & Ustun, 2004), Byers et al. (2010) found that the most prevalent 12-

month anxiety disorder was specific phobia (6.5%), followed by social phobia (3.5%),

posttraumatic stress disorder (2.1%), generalized anxiety disorder (GAD) (2.0%), panic

disorder (1.3%), and agoraphobia without panic disorder (0.8%). The total prevalence of

anxiety disorders measured was 11.6%. The authors also found that the prevalence of

pooled anxiety disorder declined with age, with rates among women significantly more

prominent than men.

Rates of anxiety are even higher when significant but subsyndromal levels of

anxiety are assessed among older adults. For example, significant levels of anxiety have

ranged from 17% to as high as 47% using the State-Trait Anxiety Inventory (STAI,

2

about the future because one cannot predict or control upcoming events (Barlow, 1988).

The focus of this research will be on anxiety regarding health among the older adult

population.

Several specific types of anxiety have been identified in the literature, such as

anxiety disorders, and trait, state, and health anxiety. Research focused on the prevalence

of specific anxiety disorders suggests they are a significant issue for older adults. Most

recently, Byers, Yaffe, Covinsky, Friedman, and Bruce (2010) examined nationally

representative estimates of age-specific 12-month prevalence rates of the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR; American

Psychiatric Association [APA], 2000) anxiety disorders among 2575 community-

dwelling adults 55 years of age and older in the National Comorbidity Survey Replication

(NCS-R) in the United States. Using the Composite International Diagnostic Interview

(CIDI; Kessler & Ustun, 2004), Byers et al. (2010) found that the most prevalent 12-

month anxiety disorder was specific phobia (6.5%), followed by social phobia (3.5%),

posttraumatic stress disorder (2.1%), generalized anxiety disorder (GAD) (2.0%), panic

disorder (1.3%), and agoraphobia without panic disorder (0.8%). The total prevalence of

anxiety disorders measured was 11.6%. The authors also found that the prevalence of

pooled anxiety disorder declined with age, with rates among women significantly more

prominent than men.

Rates of anxiety are even higher when significant but subsyndromal levels of

anxiety are assessed among older adults. For example, significant levels of anxiety have

ranged from 17% to as high as 47% using the State-Trait Anxiety Inventory (STAI,

2

Spielberger, 1983) in community dwelling seniors (Himmelfarb & Murrell, 1984; Kvaal,

Macijauskiene, Engedal, & Laake, 2001). Using the Goldberg Anxiety Scale (GS-A;

Goldberg, Bridges, Duncan-Jones, & Grayson, 1988), Richardson, Simning, He, and

Conwell (2010) found that among 377 community dwelling older adults, 27.3% had

clinically significant symptoms of anxiety (GS-A > 6).

Researchers have also investigated worry (apprehensive expectation) themes of

older adults. Montorio, Nuevo, Marquez, Izal, and Losada (2003) found that the most

frequent contents of worry among a sample of 85 older adults were related mainly to

family and personal health. Similarly, Skarborn and Nicki (1996) found health-related

worries to be the most prevalent concern among a sample of 100 community-dwelling

Canadian seniors (aged 65 and older). Wisocki (1988) found that the primary health-

related worries of 94 community seniors included worry about sensory and motor losses,

failing memory, illness or accident involving family members, loss of independence, and

depression. Rodin and Timko (1992) suggest that older adults are especially susceptible

to anxiety about failing health since it is a situation that threatens to reduce the control

they have or perceive to have over their lives.

In samples of community dwelling and primary care seniors, the prevalence and

nature of anxiety disorders indicate that health anxiety is a significant concern (Snyder &

Stanley, 2001). Health-related anxiety is also an important factor in GAD, phobias, panic

disorder, and obsessive-compulsive disorder among older adults (Snyder & Stanley,

2001). The research that has been completed to date provides evidence to suggest that a

considerable number of older adults may experience significant levels of health anxiety.

3

Spielberger, 1983) in community dwelling seniors (Himmelfarb & Murrell, 1984; Kvaal,

Macijauskiene, Engedal, & Laake, 2001). Using the Goldberg Anxiety Scale (GS-A;

Goldberg, Bridges, Duncan-Jones, & Grayson, 1988), Richardson, Simning, He, and

Conwell (2010) found that among 377 community dwelling older adults, 27.3% had

clinically significant symptoms of anxiety (GS-A > 6).

Researchers have also investigated worry (apprehensive expectation) themes of

older adults. Montorio, Nuevo, Marquez, Izal, and Losada (2003) found that the most

frequent contents of worry among a sample of 85 older adults were related mainly to

family and personal health. Similarly, Skarborn and Nicki (1996) found health-related

worries to be the most prevalent concern among a sample of 100 community-dwelling

Canadian seniors (aged 65 and older). Wisocki (1988) found that the primary health-

related worries of 94 community seniors included worry about sensory and motor losses,

failing memory, illness or accident involving family members, loss of independence, and

depression. Rodin and Timko (1992) suggest that older adults are especially susceptible

to anxiety about failing health since it is a situation that threatens to reduce the control

they have or perceive to have over their lives.

In samples of community dwelling and primary care seniors, the prevalence and

nature of anxiety disorders indicate that health anxiety is a significant concern (Snyder &

Stanley, 2001). Health-related anxiety is also an important factor in GAD, phobias, panic

disorder, and obsessive-compulsive disorder among older adults (Snyder & Stanley,

2001). The research that has been completed to date provides evidence to suggest that a

considerable number of older adults may experience significant levels of health anxiety.

3

There is only a limited amount of research that has examined health anxiety

among older adults, and no research that has examined outcomes of treatment for health

anxiety with this population. The focus of the present research was to gain a better

understanding of health anxiety among older adults and to assess the efficacy of cognitive

behavioural therapy (CBT) for health anxiety in both a standard format and a format

enhanced for older adults. In the following literature review, a description of health

anxiety followed by a summary of the cognitive behavioural (CB) theory of health

anxiety will be provided. Next, a review of research that has been conducted on health

anxiety among the older adult population and a review of some of the major research

findings associated with health anxiety in other populations that could contribute to our

knowledge of seniors will be provided. In addition, the research on anxiety among

seniors will be summarized. Attention will then be given to the CB approach to health

anxiety and treatment studies in this area to date. Finally, a summary of the issues around

enhancing the therapeutic alliance and motivation for psychotherapy among older adults

will be provided.

1.2 Health Anxiety versus Hypochondriasis

Although health anxiety and hypochondriasis share common features, they are

considered distinct constructs. Health anxiety has been conceptualized as a dimensional

construct that varies considerably from person to person, ranging in severity from mild to

severe (e.g., Barsky, Wyshak, & Klerman, 1986a; Ferguson, 2009; Salkovskis &

Warwick, 1986). Supporting this conceptualization in a recent taxometric analysis with

711 adults using the nine-item version of the Whiteley Index (WI; Pilowsky, 1967)

4

There is only a limited amount of research that has examined health anxiety

among older adults, and no research that has examined outcomes of treatment for health

anxiety with this population. The focus of the present research was to gain a better

understanding of health anxiety among older adults and to assess the efficacy of cognitive

behavioural therapy (CBT) for health anxiety in both a standard format and a format

enhanced for older adults. In the following literature review, a description of health

anxiety followed by a summary of the cognitive behavioural (CB) theory of health

anxiety will be provided. Next, a review of research that has been conducted on health

anxiety among the older adult population and a review of some of the major research

findings associated with health anxiety in other populations that could contribute to our

knowledge of seniors will be provided. In addition, the research on anxiety among

seniors will be summarized. Attention will then be given to the CB approach to health

anxiety and treatment studies in this area to date. Finally, a summary of the issues around

enhancing the therapeutic alliance and motivation for psychotherapy among older adults

will be provided.

1.2 Health Anxiety versus Hypochondriasis

Although health anxiety and hypochondriasis share common features, they are

considered distinct constructs. Health anxiety has been conceptualized as a dimensional

construct that varies considerably from person to person, ranging in severity from mild to

severe (e.g., Barsky, Wyshak, & Klerman, 1986a; Ferguson, 2009; Salkovskis &

Warwick, 1986). Supporting this conceptualization in a recent taxometric analysis with

711 adults using the nine-item version of the Whiteley Index (WI; Pilowsky, 1967)

4

scored on a five-point Likert-type scale (Barsky, Wyshak, & Klerman, 1990a), Ferguson

(2009) concluded that the pattern of results indicated that health anxiety is better

represented as a dimensional rather than a categorical construct. In another recent study

with 1,083 undergraduate students, Longley, Broman-Fulks, Calamari, Noyes, Wade, and

Orlando (in press) conducted a taxometric analysis of self report measures of

hypochondriasis to more comprehensively assess the full range of the construct.

Longley et al. (in press) evaluated the nature of these self report measures of

hypochondriasis using taxometric analysis of the following four empirically derived

symptom indicators: (a) cognitive—conviction that one is ill despite contrary evidence;

(b) perceptual—somatic sensitivity to body sensations; (c) behavioural—reassurance

seeking used to allay illness fears; and (d) affective—worry about health and illness. The

composite indicators included items from the Multidimensional Inventory of

Hypochondriacal Traits (Longley, Watson, & Noyes, 2005), Illness Attitudes Scale (IAS;

Kellner, 1987), and the WI. Longley et al. (in press) concluded that the results of

analyses provided convergent support that these self report measures of hypochondriasis

had a dimensional latent structure.

In contrast to health anxiety, hypochondriasis as specifically defined by the DSM-

IV-TR is a categorical construct and it can be distinguished from nonclinical health

anxiety by the degree of worry and conviction about having a serious disease, distress,

and interference in functioning (Barsky, Fama, Bailey, & Ahern, 1998). The presence of

health anxiety is necessary, but not sufficient, to assign a diagnosis of hypochondriasis.

To meet the diagnostic criteria for hypochondriasis, a person is required to have a six-

5

scored on a five-point Likert-type scale (Barsky, Wyshak, & Klerman, 1990a), Ferguson

(2009) concluded that the pattern of results indicated that health anxiety is better

represented as a dimensional rather than a categorical construct. In another recent study

with 1,083 undergraduate students, Longley, Broman-Fulks, Calamari, Noyes, Wade, and

Orlando (in press) conducted a taxometric analysis of self report measures of

hypochondriasis to more comprehensively assess the full range of the construct.

Longley et al. (in press) evaluated the nature of these self report measures of

hypochondriasis using taxometric analysis of the following four empirically derived

symptom indicators: (a) cognitive—conviction that one is ill despite contrary evidence;

(b) perceptual—somatic sensitivity to body sensations; (c) behavioural—reassurance

seeking used to allay illness fears; and (d) affective—worry about health and illness. The

composite indicators included items from the Multidimensional Inventory of

Hypochondriacal Traits (Longley, Watson, & Noyes, 2005), Illness Attitudes Scale (IAS;

Kellner, 1987), and the WI. Longley et al. (in press) concluded that the results of

analyses provided convergent support that these self report measures of hypochondriasis

had a dimensional latent structure.

In contrast to health anxiety, hypochondriasis as specifically defined by the DSM-

IV-TR is a categorical construct and it can be distinguished from nonclinical health

anxiety by the degree of worry and conviction about having a serious disease, distress,

and interference in functioning (Barsky, Fama, Bailey, & Ahern, 1998). The presence of

health anxiety is necessary, but not sufficient, to assign a diagnosis of hypochondriasis.

To meet the diagnostic criteria for hypochondriasis, a person is required to have a six-

5

month duration of symptoms, persistence despite medical reassurance following

appropriate medical evaluation, non-delusional intensity of beliefs regarding health, and

clinically significant interference in social, occupational, or other important areas of

functioning (APA, 2000).

Hypochondriasis is not the only disorder characterized by severe health anxiety

(Asmundson, Taylor, Sevgur, & Cox, 2001). Frequently, health anxiety co-occurs with

other clinical disorders, such as mood and anxiety disorders (e.g., illness phobia, panic

disorder; Noyes et al., 1994), and somatization disorder (Barsky, Barnett, & Cleary,

1994). Health anxiety is also commonly associated with various health conditions (e.g.,

cardiac conditions, chronic pain; Eifert, Zvolensky, & Lejuez, 2001; Hadjistavropoulos,

Owens, Hadjistavropoulos, & Asmundson, 2001). Due to the limited research on health

anxiety as a separate construct to hypochondriasis, a great deal of the research reviewed

in this paper was conducted with samples of individuals diagnosed with hypochondriasis.

This limitation should be kept in mind in reviewing the research that follows.

In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental

Disorders (APA, 2010) to be published in May 2013, the Work Group for Somatic

Symptom Disorders, which includes hypochondriasis, is recommending that this disorder

be subsumed into a new disorder called Complex Somatic Symptom Disorder (CSSD).

CSSD includes the previous diagnoses of Somatization Disorder, Undifferentiated

Somatoform Disorder, Hypochondriasis, Pain Disorder Associated With Both

Psychological Factors and a General Medical Condition, and Pain Disorder Associated

6

month duration of symptoms, persistence despite medical reassurance following

appropriate medical evaluation, non-delusional intensity of beliefs regarding health, and

clinically significant interference in social, occupational, or other important areas of

functioning (APA, 2000).

Hypochondriasis is not the only disorder characterized by severe health anxiety

(Asmundson, Taylor, Sevgur, & Cox, 2001). Frequently, health anxiety co-occurs with

other clinical disorders, such as mood and anxiety disorders (e.g., illness phobia, panic

disorder; Noyes et al., 1994), and somatization disorder (Barsky, Barnett, & Cleary,

1994). Health anxiety is also commonly associated with various health conditions (e.g.,

cardiac conditions, chronic pain; Eifert, Zvolensky, & Lejuez, 2001; Hadjistavropoulos,

Owens, Hadjistavropoulos, & Asmundson, 2001). Due to the limited research on health

anxiety as a separate construct to hypochondriasis, a great deal of the research reviewed

in this paper was conducted with samples of individuals diagnosed with hypochondriasis.

This limitation should be kept in mind in reviewing the research that follows.

In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental

Disorders (APA, 2010) to be published in May 2013, the Work Group for Somatic

Symptom Disorders, which includes hypochondriasis, is recommending that this disorder

be subsumed into a new disorder called Complex Somatic Symptom Disorder (CSSD).

CSSD includes the previous diagnoses of Somatization Disorder, Undifferentiated

Somatoform Disorder, Hypochondriasis, Pain Disorder Associated With Both

Psychological Factors and a General Medical Condition, and Pain Disorder Associated

6

With Psychological Factors. As outlined by the APA (2010), to meet criteria for CSSD,

criteria A, B, and C are necessary:

A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result

in significant disruption in daily life.

B. Overwhelming concern or preoccupation with symptoms and illness: At least three

of the following are required to meet this criterion:

(1) High level of health-related anxiety.

(2) A tendency to fear the worst about one's health or bodily symptoms

(catastrophizing).

(3) Belief in the medical seriousness of one's symptoms despite evidence to the

contrary.

(4) Health concerns and/or symptoms assume a central role in one's life

(ruminative preoccupation).

C. Chronicity: Although any one symptom may not be continuously present, the state of

being symptomatic is chronic (at least 6 months).

The following optional specifiers may be applied to a diagnosis of CSSD where

one of the following dominates the clinical presentation (APA, 2010):

1. Multiplicity of somatic complaints (previously, somatization disorder).

2. High health anxiety (previously, hypochondriasis). If patients present solely with

health-related anxiety in the absence of somatic symptoms, they may be more

appropriately diagnosed as having an anxiety disorder.

7

With Psychological Factors. As outlined by the APA (2010), to meet criteria for CSSD,

criteria A, B, and C are necessary:

A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result

in significant disruption in daily life.

B. Overwhelming concern or preoccupation with symptoms and illness: At least three

of the following are required to meet this criterion:

(1) High level of health-related anxiety.

(2) A tendency to fear the worst about one's health or bodily symptoms

(catastrophizing).

(3) Belief in the medical seriousness of one's symptoms despite evidence to the

contrary.

(4) Health concerns and/or symptoms assume a central role in one's life

(ruminative preoccupation).

C. Chronicity: Although any one symptom may not be continuously present, the state of

being symptomatic is chronic (at least 6 months).

The following optional specifiers may be applied to a diagnosis of CSSD where

one of the following dominates the clinical presentation (APA, 2010):

1. Multiplicity of somatic complaints (previously, somatization disorder).

2. High health anxiety (previously, hypochondriasis). If patients present solely with

health-related anxiety in the absence of somatic symptoms, they may be more

appropriately diagnosed as having an anxiety disorder.

7

3. Pain disorder. This classification is reserved for individuals presenting

predominantly with pain complaints who also have many of the features described

under criterion B. Patients with other presentations of pain may better fit other

psychiatric diagnoses, such as adjustment disorder or psychological factors

affecting a medical condition.

The Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-

Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are

considering the possibility that what was described as Hypochondriasis in the DSM-IV-

TR may represent a heterogeneous disorder in which some individuals may be better

considered to have CSSD and some may be better considered to have an anxiety disorder.

The website indicates that there will be ongoing discussion of this issue (APA, 2010).

Numerous researchers are in favour of viewing hypochondriasis as an anxiety

disorder given significant similarities between hypochondriasis and anxiety disorders

(e.g., Olatunji, Deacon, & Abramowitz, 2009). Like obsessive-compulsive disorder,

hypochondriasis involves intrusive, distressing thoughts and repetitive behaviours

(Olatunji, et al., 2009). In both hypochondriasis and obsessive-compulsive disorder,

dysfunctional beliefs (e.g., overestimation of the likelihood and severity of having an

illness, intolerance of uncertainty about the meaning of feared stimuli) are associated with

increased anxiety and distress, and subsequent attempts to check or seek reassurance

about the symptoms are associated with an immediate decrease in anxiety (Olatunji et al.,

2009).

8

3. Pain disorder. This classification is reserved for individuals presenting

predominantly with pain complaints who also have many of the features described

under criterion B. Patients with other presentations of pain may better fit other

psychiatric diagnoses, such as adjustment disorder or psychological factors

affecting a medical condition.

The Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-

Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are

considering the possibility that what was described as Hypochondriasis in the DSM-IV-

TR may represent a heterogeneous disorder in which some individuals may be better

considered to have CSSD and some may be better considered to have an anxiety disorder.

The website indicates that there will be ongoing discussion of this issue (APA, 2010).

Numerous researchers are in favour of viewing hypochondriasis as an anxiety

disorder given significant similarities between hypochondriasis and anxiety disorders

(e.g., Olatunji, Deacon, & Abramowitz, 2009). Like obsessive-compulsive disorder,

hypochondriasis involves intrusive, distressing thoughts and repetitive behaviours

(Olatunji, et al., 2009). In both hypochondriasis and obsessive-compulsive disorder,

dysfunctional beliefs (e.g., overestimation of the likelihood and severity of having an

illness, intolerance of uncertainty about the meaning of feared stimuli) are associated with

increased anxiety and distress, and subsequent attempts to check or seek reassurance

about the symptoms are associated with an immediate decrease in anxiety (Olatunji et al.,

2009).

8

The prominent preoccupation with bodily symptoms in both hypochondriasis and

panic disorder has also been identified (Barky, Barnett, & Clearly, 1994). The cognitive

and behavioural mechanisms that maintain hypochondriasis also appear similar to those

that maintain panic disorder, with the exception that the feared catastrophe is foreseen as

occurring immediately in panic disorder, resulting in the urge to escape right away

(Olatunji et al., 2009). In addition, both panic disorder and hypochondriasis involve

hypervigilance to bodily sensations and acute sensitivity to harmless or normal bodily

sensations (Olatunji, Deacon, Abramowitz, & Valentiner, 2007). This tendency to

misinterpret innocuous bodily symptoms as physically harmful (i.e., anxiety sensitivity)

is associated with both panic disorder and hypochondriasis (Deacon & Abramowitz,

2008). The combination of excessive body vigilance and high anxiety sensitivity leads to

the catastrophic misinterpretations of somatic cues (`this symptom means I have cancer'),

which evokes hypochondriacal fear and panic attacks. The coping strategies, such as

body checking and seeking medical reassurance (Deacon, Lickel, & Abramowitz, 2008),

that individuals with hypochondriasis and panic disorder use to manage their anxiety

paradoxically appear to maintain or even exacerbate the cognitive mechanisms that

underlie these disorders (Olatunji et al., 2009). In this study, the focus will be on those

individuals identified as having elevated health anxiety as compared to hypochondriasis.

1.3 Features Associated with Health Anxiety

1.3.1 Cognitive and Somatic Features of Health Anxiety

The cognitive features associated with excessive health anxiety include disease

conviction, disease preoccupation, hypervigilance for bodily changes, and difficulty with

9

The prominent preoccupation with bodily symptoms in both hypochondriasis and

panic disorder has also been identified (Barky, Barnett, & Clearly, 1994). The cognitive

and behavioural mechanisms that maintain hypochondriasis also appear similar to those

that maintain panic disorder, with the exception that the feared catastrophe is foreseen as

occurring immediately in panic disorder, resulting in the urge to escape right away

(Olatunji et al., 2009). In addition, both panic disorder and hypochondriasis involve

hypervigilance to bodily sensations and acute sensitivity to harmless or normal bodily

sensations (Olatunji, Deacon, Abramowitz, & Valentiner, 2007). This tendency to

misinterpret innocuous bodily symptoms as physically harmful (i.e., anxiety sensitivity)

is associated with both panic disorder and hypochondriasis (Deacon & Abramowitz,

2008). The combination of excessive body vigilance and high anxiety sensitivity leads to

the catastrophic misinterpretations of somatic cues ('this symptom means I have cancer'),

which evokes hypochondriacal fear and panic attacks. The coping strategies, such as

body checking and seeking medical reassurance (Deacon, Lickel, & Abramowitz, 2008),

that individuals with hypochondriasis and panic disorder use to manage their anxiety

paradoxically appear to maintain or even exacerbate the cognitive mechanisms that

underlie these disorders (Olatunji et al., 2009). In this study, the focus will be on those

individuals identified as having elevated health anxiety as compared to hypochondriasis.

1.3 Features Associated with Health Anxiety

1.3.1 Cognitive and Somatic Features of Health Anxiety

The cognitive features associated with excessive health anxiety include disease

conviction, disease preoccupation, hypervigilance for bodily changes, and difficulty with

9

acceptance of medical reassurance (APA, 2000). Individuals with health anxiety believe

strongly that they are physically ill; that is, they have strong disease conviction,

adamantly believing that they have a serious disease that has been undetected by medical

examinations. Disease conviction is associated with preoccupation with one's bodily

appearance and functioning and hypervigilance for bodily sensations. People with

elevated health anxiety also typically resist the idea that they are suffering from a mental

disorder. However, they are often able to recognize, at least in their calmer moments,

that their health concerns are overstated (Taylor & Asmundson, 2004).

People with high levels of health anxiety also have a tendency to misinterpret the

seriousness of harmless, natural bodily sensations, and appear to overestimate the

seriousness of symptoms of general medical conditions (Cote et al., 1996). Complaints

may be in the form of highly specific symptoms, or vague, variable, and generalized (e.g.,

aching "all over") symptoms. Frequent specific symptoms include localized pain, bowel

complaints (e.g., changes in bowel habits), and cardio-respiratory sensations (e.g., chest

tightness).

1.3.2 Behaviours Associated with Health Anxiety

Abramowitz, Schwartz, and Whiteside (2002) indicate that engaging in certain

behaviours to bring about safety is a logical and adaptive response for someone who

believes himself or herself to be in danger. These safety-seeking behaviours act to reduce

anxiety regarding the danger or potential for threat. However, if the perception of danger

is based on an incorrect belief, Abramowitz et al. (2002) indicate that safety-seeking

behaviours also have the effect of preventing someone from noticing that their fear is

10

acceptance of medical reassurance (APA, 2000). Individuals with health anxiety believe

strongly that they are physically ill; that is, they have strong disease conviction,

adamantly believing that they have a serious disease that has been undetected by medical

examinations. Disease conviction is associated with preoccupation with one's bodily

appearance and functioning and hypervigilance for bodily sensations. People with

elevated health anxiety also typically resist the idea that they are suffering from a mental

disorder. However, they are often able to recognize, at least in their calmer moments,

that their health concerns are overstated (Taylor & Asmundson, 2004).

People with high levels of health anxiety also have a tendency to misinterpret the

seriousness of harmless, natural bodily sensations, and appear to overestimate the

seriousness of symptoms of general medical conditions (Cote et al., 1996). Complaints

may be in the form of highly specific symptoms, or vague, variable, and generalized (e.g.,

aching "all over") symptoms. Frequent specific symptoms include localized pain, bowel

complaints (e.g., changes in bowel habits), and cardio-respiratory sensations (e.g., chest

tightness).

1.3.2 Behaviours Associated with Health Anxiety

Abramowitz, Schwartz, and Whiteside (2002) indicate that engaging in certain

behaviours to bring about safety is a logical and adaptive response for someone who

believes himself or herself to be in danger. These safety-seeking behaviours act to reduce

anxiety regarding the danger or potential for threat. However, if the perception of danger

is based on an incorrect belief, Abramowitz et al. (2002) indicate that safety-seeking

behaviours also have the effect of preventing someone from noticing that their fear is

10

inaccurate. One safety-seeking behaviour identified in individuals with elevated health

anxiety is reassurance seeking (e.g., from family physicians). When individuals with

elevated health anxiety turn to physicians, medical reference books, or family and friends

for reassurance, he or she will often experience a temporary reduction in anxiety and

distress. Abramowitz et al. (2002) indicate that this kind of reassurance seeking becomes

a habit, and the individual will come to rely on such reassurance to relieve health anxiety

which, in turn, strengthens inaccurate beliefs about health. Frequent checking of one's

body (e.g., recurrent prodding of the abdomen) is another safety-seeking behaviour, and it

not only prevents disconfirmation of inaccurate beliefs, but also increases the symptoms

that were the initial source of the misinterpretation (Abramowitz et al., 2002). For

instance, individuals who are focused on particular bodily sensations often perform

repeated examinations on the affected areas (e.g., excessively checking blood pressure).

These repeated examinations can have the effect of increasing discomfort in the area,

which is then misinterpreted as a sign of illness (Abramowitz et al., 2002). Searching for

other sources of information on the disease (e.g., checking the Internet), and trying

various kinds of remedies (e.g., herbal medications) are also types of common safety-

seeking behaviours (Taylor & Asmundson, 2004).

Avoidance and escape from stimuli that the individual believes to be associated

with disease are other common safety-seeking behaviours (Taylor & Asmundson, 2004).

For example, a highly health anxious individual may avoid medical buildings such as

clinics and hospitals, avoid sickly looking people, and limit contact with people who

come in contact with illness such as physicians and nurses (Taylor & Asmundson, 2004).

11

inaccurate. One safety-seeking behaviour identified in individuals with elevated health

anxiety is reassurance seeking (e.g., from family physicians). When individuals with

elevated health anxiety turn to physicians, medical reference books, or family and friends

for reassurance, he or she will often experience a temporary reduction in anxiety and

distress. Abramowitz et al. (2002) indicate that this kind of reassurance seeking becomes

a habit, and the individual will come to rely on such reassurance to relieve health anxiety

which, in turn, strengthens inaccurate beliefs about health. Frequent checking of one's

body (e.g., recurrent prodding of the abdomen) is another safety-seeking behaviour, and it

not only prevents disconfirmation of inaccurate beliefs, but also increases the symptoms

that were the initial source of the misinterpretation (Abramowitz et al., 2002). For

instance, individuals who are focused on particular bodily sensations often perform

repeated examinations on the affected areas (e.g., excessively checking blood pressure).

These repeated examinations can have the effect of increasing discomfort in the area,

which is then misinterpreted as a sign of illness (Abramowitz et al., 2002). Searching for

other sources of information on the disease (e.g., checking the Internet), and trying

various kinds of remedies (e.g., herbal medications) are also types of common safety-

seeking behaviours (Taylor & Asmundson, 2004).

Avoidance and escape from stimuli that the individual believes to be associated

with disease are other common safety-seeking behaviours (Taylor & Asmundson, 2004).

For example, a highly health anxious individual may avoid medical buildings such as

clinics and hospitals, avoid sickly looking people, and limit contact with people who

come in contact with illness such as physicians and nurses (Taylor & Asmundson, 2004).

11

Inaccurate beliefs that could be self-corrected if the person had faced the feared stimuli

and the feared negative outcomes did not materialize (Abramowitz et al., 2002) are

maintained through avoidance.

Studies have demonstrated the significance of safety behaviours in health anxious

individuals. Abramowitz and Moore (2007) demonstrated that performing personally

relevant safety behaviours produced a quick reduction in anxiety in individuals who met

DSM-IV-TR criteria for hypochondriasis, when compared with individuals who engaged

in non-safety behaviour activities. In addition, Abramowitz et al. (2007) found that in

medically healthy university students, health anxiety was a significant predictor of safety

behaviours, which is consistent with the CB model of health anxiety.

1.3.3 Patient-Physician Relationships

Patients with health anxiety and physicians have often been found to have

problematic relationships. Frustration and resentment on the part of both the physician

and patient are fairly common (APA, 2000). For example, Persing, Stuart, Noyes, and

Happel (2000) interviewed 20 patients with DSM-III-R (APA, 1987) hypochondriasis and

26 patients without hypochondriasis from a general medicine clinic to obtain information

on the patients' recent health problems and medical care. Patients with hypochondriasis

and patients without hypochondriasis made an equal number of positive comments, but

patients with hypochondriasis made significantly more negative comments about

physicians' professional characteristics (e.g., ineffective, hurried or careless, not

accepting), patients' own characteristics (e.g., helpless, hopeless, reluctant to seek

medical care), and total negative comments. Many patients viewed physicians they had

12

Inaccurate beliefs that could be self-corrected if the person had faced the feared stimuli

and the feared negative outcomes did not materialize (Abramowitz et al., 2002) are

maintained through avoidance.

Studies have demonstrated the significance of safety behaviours in health anxious

individuals. Abramowitz and Moore (2007) demonstrated that performing personally

relevant safety behaviours produced a quick reduction in anxiety in individuals who met

DSM-IV-TR criteria for hypochondriasis, when compared with individuals who engaged

in non-safety behaviour activities. In addition, Abramowitz et al. (2007) found that in

medically healthy university students, health anxiety was a significant predictor of safely

behaviours, which is consistent with the CB model of health anxiety.

1.3.3 Patient-Physician Relationships

Patients with health anxiety and physicians have often been found to have

problematic relationships. Frustration and resentment on the part of both the physician

and patient are fairly common (APA, 2000). For example, Persing, Stuart, Noyes, and

Happel (2000) interviewed 20 patients with DSM-III-R (APA, 1987) hypochondriasis and

26 patients without hypochondriasis from a general medicine clinic to obtain information

on the patients' recent health problems and medical care. Patients with hypochondriasis

and patients without hypochondriasis made an equal number of positive comments, but

patients with hypochondriasis made significantly more negative comments about

physicians' professional characteristics (e.g., ineffective, hurried or careless, not

accepting), patients' own characteristics (e.g., helpless, hopeless, reluctant to seek

medical care), and total negative comments. Many patients viewed physicians they had

12

seen as unskilled and uncaring. They indicated that, in many instances, their

relationships with physicians had suffered from poor communication and cooperation.

Notably, although these patients were diagnosed with hypochondriasis by Persing et al.

(2000), none were assigned a diagnosis of hypochondriasis by their own physician.

Similarly, Warwick and Salkovskis (1989) indicated that individuals with health anxiety

believe that their physicians see them as excessively concerned about their health, which

may actually be a realistic assessment of their physicians' appraisal. When Barsky,

Wyshak, Latham, and Klerman (1991) examined physicians' assessments of the patients

with hypochondriasis, they found that the physicians' use of the term hypochondriasis

was closely associated with their frustration with the patient. They also found that

physicians complained that patients with hypochondriasis bring forth baseless

complaints, and are demanding, difficult, and ungrateful (Barsky, Wyshak, Latham, et al.,

1991).

More recent research conducted by Noyes et al. (2003) examined the relationship

between health anxiety and the patient-physician relationship among 162 patients

attending a general medicine clinic. They found that increased health anxiety was

negatively correlated with perceived physician characteristics and satisfaction with care.

A further study conducted by many of the same researchers, Noyes, Longley, Langbehn,

Stuart, and Kukoyi (2010), examined the association between health anxiety using the

IAS and the physician-patient relationship using the Physician-Patient Relationship Scale

(Noyes et al., 2010) with a sample of 310 family medicine patients. Noyes et al. (2010)

13

seen as unskilled and uncaring. They indicated that, in many instances, their

relationships with physicians had suffered from poor communication and cooperation.

Notably, although these patients were diagnosed with hypochondriasis by Persing et al.

(2000), none were assigned a diagnosis of hypochondriasis by their own physician.

Similarly, Warwick and Salkovskis (1989) indicated that individuals with health anxiety

believe that their physicians see them as excessively concerned about their health, which

may actually be a realistic assessment of their physicians' appraisal. When Barsky,

Wyshak, Latham, and Klerman (1991) examined physicians' assessments of the patients

with hypochondriasis, they found that the physicians' use of the term hypochondriasis

was closely associated with their frustration with the patient. They also found that

physicians complained that patients with hypochondriasis bring forth baseless

complaints, and are demanding, difficult, and ungrateful (Barsky, Wyshak, Latham, et al.,

1991).

More recent research conducted by Noyes et al. (2003) examined the relationship

between health anxiety and the patient-physician relationship among 162 patients

attending a general medicine clinic. They found that increased health anxiety was

negatively correlated with perceived physician characteristics and satisfaction with care.

A further study conducted by many of the same researchers, Noyes, Longley, Langbehn,

Stuart, and Kukoyi (2010), examined the association between health anxiety using the

IAS and the physician-patient relationship using the Physician-Patient Relationship Scale

(Noyes et al., 2010) with a sample of 310 family medicine patients. Noyes et al. (2010)

13

also found that among family medical patients, health anxiety was associated with a

poorer therapeutic patient-physician relationship.

1.4 Theoretical Approach to Health Anxiety

There are several theories or models of health anxiety, such as psychodynamic,

biological, behavioural, interpersonal, and CB. Based on their review of the empirical

literature, Taylor and Asmundson (2004) suggest that the CB theory of health anxiety is

particularly informative in terms of usefulness of the theory to explain predisposing

factors or vulnerabilities, precipitating factors, maintaining factors, and protective factors

(prevention of development, persistence, or increase of the problem). The CB theory is

also empirically supported, whereas there is limited evidence to support the alternative

theories (see Taylor & Asmundson, 2004; Taylor, Asmundson, & Coons, 2005). As

such, this approach will be the focus in the current research.

According to the CB model of health anxiety (see Figure 1), individuals suffering

from persistent health anxiety are expected to misinterpret benign physical sensations,

bodily variations, and other health information as signs of serious physical illness

(Salkovskis, 1989, 1996; Salkovskis & Clark, 1993; Salkovskis & Warwick, 1986;

Warwick & Salkovskis, 1990). The greater the level of threat perceived by the sufferer,

the greater are the consequences of this misinterpretation. The level of threat is predicted

to be a function of the interactions among the perceived probability of the disease,

perceived dreadfulness or cost of the disease (e.g., pain and suffering caused by the

disease, emotional impact on family and friends), perceived ability to prevent the disease

from worsening, and perceived likelihood of being able to affect the course of the disease

14

also found that among family medical patients, health anxiety was associated with a

poorer therapeutic patient-physician relationship.

1.4 Theoretical Approach to Health Anxiety

There are several theories or models of health anxiety, such as psychodynamic,

biological, behavioural, interpersonal, and CB. Based on their review of the empirical

literature, Taylor and Asmundson (2004) suggest that the CB theory of health anxiety is

particularly informative in terms of usefulness of the theory to explain predisposing

factors or vulnerabilities, precipitating factors, maintaining factors, and protective factors

(prevention of development, persistence, or increase of the problem). The CB theory is

also empirically supported, whereas there is limited evidence to support the alternative

theories (see Taylor & Asmundson, 2004; Taylor, Asmundson, & Coons, 2005). As

such, this approach will be the focus in the current research.

According to the CB model of health anxiety (see Figure 1), individuals suffering

from persistent health anxiety are expected to misinterpret benign physical sensations,

bodily variations, and other health information as signs of serious physical illness

(Salkovskis, 1989, 1996; Salkovskis & Clark, 1993; Salkovskis & Warwick, 1986;

Warwick & Salkovskis, 1990). The greater the level of threat perceived by the sufferer,

the greater are the consequences of this misinterpretation. The level of threat is predicted

to be a function of the interactions among the perceived probability of the disease,

perceived dreadfulness or cost of the disease (e.g., pain and suffering caused by the

disease, emotional impact on family and friends), perceived ability to prevent the disease

from worsening, and perceived likelihood of being able to affect the course of the disease

14

Previous illness experience and other medical factors

pretatton and resulting anxiety

Perceived likelihood of

A nviety illness

Perceived X cost awfulness

burden of the illness

Perceived ability Perception of extent that to cope with the X external rescue factors illness will help

Adapted from Salkovskis & Warwick 2001

Figure 1. Cognitive behavioural model of the development of health anxiety

Note. From Salkovskis, P. M., & Warwick, H. M. C. (2001). Making sense of

hypochondriasis: A cognitive model of health anxiety. In G.J.G. Asmundson, S. Taylor,

and B.J. Cox (Eds.), Health Anxiety. Copyright 2001 by John Wiley & Sons, Ltd.

15

Previous illness experience and other medical factors

Misinterpretafctoti and rssultfliE anxiety

Anxietr =

Perceived likelihood of illness

Perceived cost awfiikiess, burden of the ittness

Perceived ability Perception of extent that to cope with the X external rescue factors iBness will help

Adapted iram Salkovskis & Warwick, 2901

Figure I. Cognitive behavioural model of the development of health anxiety

Note. From Salkovskis, P. M., & Warwick, H. M. C. (2001). Making sense of

hypochondriasis: A cognitive model of health anxiety. In G.J.G. Asmundson, S. Taylor,

and B.J. Cox (Eds.), Health Anxiety. Copyright 2001 by John Wiley & Sons, Ltd.

15

(i.e., being able to cope with the disease and the likelihood of outside factors coming to

the aid of the individual).

1.4.1 Misinterpretations and Maintenance of Health Anxiety

According to the CB model, it is hypothesized that the tendency to misinterpret

health-related information is a function of the individual's specific knowledge and past

experiences of illness, which have lead to the formation of inflexible or negative

assumptions about symptoms, disease, medical care, etc. These inflexible or negative

assumptions about health, coupled with a critical incident, are expected to generate

specific misinterpretations about health (Salkovskis & Warwick, 2001). General health-

related assumptions can arise from a wide variety of sources, including early health- and

illness-related experiences, later events such as unexpected or unpleasant illness in the

person's social group, and information in the media (Salkovskis & Warwick, 2001).

However, when these assumptions are relatively inflexible and extreme, it is expected

that this will lead to more severe and persistent health anxiety (Salkovskis & Warwick,

2001). For example, it is common for people to believe that persistent and intense

physical pain of an unusual and unexplained type could be a sign of ill health (Salkovskis

& Warwick, 2001). In an individual prone to health anxiety, however, he or she would

have a tendency to believe that any unexplained change in their body is always going to

be a sign of serious illness (Salkovskis & Warwick, 2001).

Marcus, Gurley, Marchi, and Bauer (2007) conducted a review of the literature

examining tenants of the CB model including: (a) whether health-anxious individuals

hold distinct assumptions about health and illness and cognitive processes involved in

16

(i.e., being able to cope with the disease and the likelihood of outside factors coming to

the aid of the individual).

1.4.1 Misinterpretations and Maintenance of Health Anxiety

According to the CB model, it is hypothesized that the tendency to misinterpret

health-related information is a function of the individual's specific knowledge and past

experiences of illness, which have lead to the formation of inflexible or negative

assumptions about symptoms, disease, medical care, etc. These inflexible or negative

assumptions about health, coupled with a critical incident, are expected to generate

specific misinterpretations about health (Salkovskis & Warwick, 2001). General health-

related assumptions can arise from a wide variety of sources, including early health- and

illness-related experiences, later events such as unexpected or unpleasant illness in the

person's social group, and information in the media (Salkovskis & Warwick, 2001).

However, when these assumptions are relatively inflexible and extreme, it is expected

that this will lead to more severe and persistent health anxiety (Salkovskis & Warwick,

2001). For example, it is common for people to believe that persistent and intense

physical pain of an unusual and unexplained type could be a sign of ill health (Salkovskis

& Warwick, 2001). In an individual prone to health anxiety, however, he or she would

have a tendency to believe that any unexplained change in their body is always going to

be a sign of serious illness (Salkovskis & Warwick, 2001).

Marcus, Gurley, Marchi, and Bauer (2007) conducted a review of the literature

examining tenants of the CB model including: (a) whether health-anxious individuals

hold distinct assumptions about health and illness and cognitive processes involved in

16

health anxiety, (b) if triggering these assumptions leads to increased health anxious

concerns, and (c) whether these individuals perceive their bodily sensations differently

from others (i.e., experience greater somatosensory amplification). In their review,

Marcus et al. (2007) examined which aspects of the CB model have been subjected to

empirical testing and they meta-analyzed the results of these studies to determine the

magnitude of the support for the model.

Dysfunctional Assumptions about Health and Illness and Cognitive Processes in

Health Anxiety. As reviewed by Marcus et al. (2007), researchers have been able to

examine the extent to which individuals with elevated health anxiety hold dysfunctional

assumptions about health by asking participants to either indicate which illness they

would assume they had if they experienced an ambiguous symptom or to estimate the

likelihood that such certain ambiguous symptoms are a sign of a catastrophic illness.

Overall, Marcus et al.'s (2007) review suggested that individuals with elevated health

anxiety do indeed hold dysfunctional assumptions about health. Several studies outlined

by Marcus et al. (2007) serve to highlight these findings. For example, Hitchcock and

Mathews (1992) found that college students higher in health anxiety, as measured by the

IAS, were more likely to interpret bodily sensations (e.g., chest tightness) as indicative of

catastrophic illness (e.g., having a heart attack) than were students who scored lower on

the IAS. Marcus (1999) found that among college students, IAS scores positively

correlated with estimates of the likelihood that ambiguous symptoms (e.g., headache)

were indicative of serious illnesses (e.g., brain tumour). Barsky, Coeytaux, Remy,

Sarnie, and Cleary (1993) found that patients diagnosed with hypochondriasis identify

17

health anxiety, (b) if triggering these assumptions leads to increased health anxious

concerns, and (c) whether these individuals perceive their bodily sensations differently

from others (i.e., experience greater somatosensory amplification). In their review,

Marcus et al. (2007) examined which aspects of the CB model have been subjected to

empirical testing and they meta-analyzed the results of these studies to determine the

magnitude of the support for the model.

Dysfunctional Assumptions about Health and Illness and Cognitive Processes in

Health Anxiety. As reviewed by Marcus et al. (2007), researchers have been able to

examine the extent to which individuals with elevated health anxiety hold dysfunctional

assumptions about health by asking participants to either indicate which illness they

would assume they had if they experienced an ambiguous symptom or to estimate the

likelihood that such certain ambiguous symptoms are a sign of a catastrophic illness.

Overall, Marcus et al.'s (2007) review suggested that individuals with elevated health

anxiety do indeed hold dysfunctional assumptions about health. Several studies outlined

by Marcus et al. (2007) serve to highlight these findings. For example, Hitchcock and

Mathews (1992) found that college students higher in health anxiety, as measured by the

IAS, were more likely to interpret bodily sensations (e.g., chest tightness) as indicative of

catastrophic illness (e.g., having a heart attack) than were students who scored lower on

the IAS. Marcus (1999) found that among college students, IAS scores positively

correlated with estimates of the likelihood that ambiguous symptoms (e.g., headache)

were indicative of serious illnesses (e.g., brain tumour). Barsky, Coeytaux, Remy,

Sarnie, and Cleary (1993) found that patients diagnosed with hypochondriasis identify

17

more physical symptoms as indicating that a person is "not healthy" than do medical

patients who do not have hypochondriasis.

Also reviewed by Marcus et al. (2007) was the extent to which information

processing biases may exist in individuals with health anxiety. This was of interest as

information processing biases are predicted to occur in individuals with elevated health

anxiety when they inadvertently gather evidence to support inaccurate beliefs (Salkovskis

& Warwick, 2001). For example, a self-maintaining confirmatory bias can occur once a

critical incident (e.g., noticing unfamiliar bodily sensations, hearing details of illness in a

close family member, or reading information about illness) has activated health-related

assumptions and resulted in misinterpretations of bodily symptoms. This would result in

the individual selectively attending to information that is consistent with illness beliefs

and ignoring information that is inconsistent with these beliefs. That is, once these illness

concerns are activated, the person will focus their attention on previously unnoticed

bodily variations. These bodily changes are viewed as new phenomena and are

consistent with the belief that illness or disease is present. Adding to this process, people

with excessive health anxiety may spend a great deal of time attending to their bodies,

thereby increasing the chances of noticing bodily sensations (Kellner, Abbott, Winslow,

& Pathak, 1987).

As reviewed by Marcus et al. (2007), an attentional bias towards certain types of

information among individuals with heightened levels of health anxiety has been reported

by researchers using various research protocols. In one such study, investigators

identified that university students with high scores on the IAS performed more poorly

18

more physical symptoms as indicating that a person is "not healthy" than do medical

patients who do not have hypochondriasis.

Also reviewed by Marcus et al. (2007) was the extent to which information

processing biases may exist in individuals with health anxiety. This was of interest as

information processing biases are predicted to occur in individuals with elevated health

anxiety when they inadvertently gather evidence to support inaccurate beliefs (Salkovskis

& Warwick, 2001). For example, a self-maintaining confirmatory bias can occur once a

critical incident (e.g., noticing unfamiliar bodily sensations, hearing details of illness in a

close family member, or reading information about illness) has activated health-related

assumptions and resulted in misinterpretations of bodily symptoms. This would result in

the individual selectively attending to information that is consistent with illness beliefs

and ignoring information that is inconsistent with these beliefs. That is, once these illness

concerns are activated, the person will focus their attention on previously unnoticed

bodily variations. These bodily changes are viewed as new phenomena and are

consistent with the belief that illness or disease is present. Adding to this process, people

with excessive health anxiety may spend a great deal of time attending to their bodies,

thereby increasing the chances of noticing bodily sensations (Kellner, Abbott, Winslow,

&Pathak, 1987).

As reviewed by Marcus et al. (2007), an attentional bias towards certain types of

information among individuals with heightened levels of health anxiety has been reported

by researchers using various research protocols. In one such study, investigators

identified that university students with high scores on the IAS performed more poorly

18

during an attention-concentration task than students with low scores on the IAS (Pauli,

Schwenzer, Brody, Rau, & Birbaumer, 1993). Participants were informed that they

would receive a painful stimulus during the second part of a test, while the first part

would be pain-free. The expectancy of a forthcoming pain stimulus reduced the

performance of students with high IAS scores in both parts of the test. Students with low

scores on the IAS, on the other hand, displayed significantly better performance in the

first, pain-free part of the test compared to the second, pain-related part of the test.

Individuals with elevated levels of health anxiety appeared to have difficulty distracting

their attention from the pain stimulus and concentrating on the task at hand, even though

they were aware that the pain stimulus would not be applied until after they had reached a

certain point in the task (Pauli et al., 1993). However, two studies by Brown, Kosslyn,

Delamater, Fama, and Barsky (1999) that examined recall of health-related words yielded

inconsistent results. They found that individuals with elevated health anxiety did not

perceive more health-related words than words not related to health. In fact, these

individuals showed an unexpected bias against reporting health-related words. That is,

individuals with elevated health anxiety committed more errors of omission for health

than for nonhealth words, whereas the group without health anxious beliefs correctly

reported similar numbers of each. These findings, however, were not replicated in the

clinical sample (Brown et al., 1999).

Owens, Asmundson, Hadjistavropoulos, and Owens (2004) identified that

individuals with heightened levels of health anxiety spent significantly more time

attending to illness-related words than individuals with lower levels of health anxiety.

19

during an attention-concentration task than students with low scores on the IAS (Pauli,

Schwenzer, Brody, Rau, & Birbaumer, 1993). Participants were informed that they

would receive a painful stimulus during the second part of a test, while the first part

would be pain-free. The expectancy of a forthcoming pain stimulus reduced the

performance of students with high IAS scores in both parts of the test. Students with low

scores on the IAS, on the other hand, displayed significantly better performance in the

first, pain-free part of the test compared to the second, pain-related part of the test.

Individuals with elevated levels of health anxiety appeared to have difficulty distracting

their attention from the pain stimulus and concentrating on the task at hand, even though

they were aware that the pain stimulus would not be applied until after they had reached a

certain point in the task (Pauli et al., 1993). However, two studies by Brown, Kosslyn,

Delamater, Fama, and Barsky (1999) that examined recall of health-related words yielded

inconsistent results. They found that individuals with elevated health anxiety did not

perceive more health-related words than words not related to health. In fact, these

individuals showed an unexpected bias against reporting health-related words. That is,

individuals with elevated health anxiety committed more errors of omission for health

than for nonhealth words, whereas the group without health anxious beliefs correctly

reported similar numbers of each. These findings, however, were not replicated in the

clinical sample (Brown et al., 1999).

Owens, Asmundson, Hadjistavropoulos, and Owens (2004) identified that

individuals with heightened levels of health anxiety spent significantly more time

attending to illness-related words than individuals with lower levels of health anxiety.

19

Specifically, on a modified Stroop task, individuals with high health anxiety had

significantly slower colour-naming response times to illness-related words when

compared to individuals with low to moderate health anxiety. The specificity of the bias

was supported by a failure to find slower response times for either negative or positive

groups of words. Thus, these results indicate that individuals with elevated levels of

health anxiety appear to display an attentional bias for illness-related information. Also

in support of this finding, medical patients with hypochondriasis have been found to

recall more pain-related words (e.g., stinging, burning) than medical patients without

hypochondriasis (Pauli & Alpers, 2002). Lecci and Cohen (2002), on the other hand,

only found this Stroop interference of illness-related words when they first induced

illness-concern in their participants by telling them that their blood pressure was too high.

In the control condition, which was similar to Owens et al.'s (2004) procedure, there was

no Stroop interference for illness-related words.

Marcus et al. (2007) indicated that some of the positive findings in this area

suggest that future research examining cognitive processes in health anxiety may prove to

be confirming of the predictions, but there is not yet sufficient evidence to conclude that

individuals with health anxiety process illness-related materials differently from

nonhypochondriacal individuals, even if the contents of their health-related beliefs do

differ.

Triggers for Health Anxiety. Again, as summarized in Marcus et al. (2007),

researchers have also examined Salkovskis and Warwick's (1986) supposition that

exposure to illness-related materials triggers increased hypochondriacal concerns or

20

Specifically, on a modified Stroop task, individuals with high health anxiety had

significantly slower colour-naming response times to illness-related words when

compared to individuals with low to moderate health anxiety. The specificity of the bias

was supported by a failure to find slower response times for either negative or positive

groups of words. Thus, these results indicate that individuals with elevated levels of

health anxiety appear to display an attentional bias for illness-related information. Also

in support of this finding, medical patients with hypochondriasis have been found to

recall more pain-related words (e.g., stinging, burning) than medical patients without

hypochondriasis (Pauli & Alpers, 2002). Lecci and Cohen (2002), on the other hand,

only found this Stroop interference of illness-related words when they first induced

illness-concern in their participants by telling them that their blood pressure was too high.

In the control condition, which was similar to Owens et al.'s (2004) procedure, there was

no Stroop interference for illness-related words.

Marcus et al. (2007) indicated that some of the positive findings in this area

suggest that future research examining cognitive processes in health anxiety may prove to

be confirming of the predictions, but there is not yet sufficient evidence to conclude that

individuals with health anxiety process illness-related materials differently from

nonhypochondriacal individuals, even if the contents of their health-related beliefs do

differ.

Triggers for Health Anxiety. Again, as summarized in Marcus et al. (2007),

researchers have also examined Salkovskis and Warwick's (1986) supposition that

exposure to illness-related materials triggers increased hypochondriacal concerns or

20

anxiety in health-anxious individuals. Lecci and Cohen (2002) reported on two studies in

which they primed college student participants by giving them a medical exam and

informing them that their blood pressures were dangerously high. In both studies,

students in the experimental condition who reported high levels of somatosensory

amplification (i.e., a tendency to perceive normal somatic and visceral sensations as being

relatively intense, disturbing and noxious; Barsky, Wyshak, & Klerman, 1990) displayed

greater interference on a modified Stroop task for illness-related words, suggesting that

the bogus medical feedback activated illness-related concerns. Furthermore, in both

studies, students in the experimental condition who reported high levels of illness

preoccupation on the WI displayed greater Stroop interference for all words, perhaps

resulting from increased arousal and anxiety.

In another study, Marcus (1999) attempted to trigger anxiety in college students

using a scrambled sentences task that included illness-related words (e.g., cancer).

Although IAS scores were positively related to state anxiety scores for students in the

control condition, contrary to the CB model, there was no relationship between IAS

scores and anxiety in the priming condition. In other words, priming with illness-related

words did not lead those students who were more health anxious to become more

anxious. Instead, it appeared that the students lower in health anxiety became as anxious

as the students with elevated health anxiety. Marcus et al. (2007) indicated that Marcus's

(1999) priming task was more indirect and subtle than the one used by Lecci and Cohen

(2002), but they felt the inconsistent results could also be due to the very different

dependent variables that were used in each study (i.e., Stroop interference versus self-

21

anxiety in health-anxious individuals. Lecci and Cohen (2002) reported on two studies in

which they primed college student participants by giving them a medical exam and

informing them that their blood pressures were dangerously high. In both studies,

students in the experimental condition who reported high levels of somatosensory

amplification (i.e., a tendency to perceive normal somatic and visceral sensations as being

relatively intense, disturbing and noxious; Barsky, Wyshak, & Klerman, 1990) displayed

greater interference on a modified Stroop task for illness-related words, suggesting that

the bogus medical feedback activated illness-related concerns. Furthermore, in both

studies, students in the experimental condition who reported high levels of illness

preoccupation on the WI displayed greater Stroop interference for all words, perhaps

resulting from increased arousal and anxiety.

In another study, Marcus (1999) attempted to trigger anxiety in college students

using a scrambled sentences task that included illness-related words (e.g., cancer).

Although IAS scores were positively related to state anxiety scores for students in the

control condition, contrary to the CB model, there was no relationship between IAS

scores and anxiety in the priming condition. In other words, priming with illness-related

words did not lead those students who were more health anxious to become more

anxious. Instead, it appeared that the students lower in health anxiety became as anxious

as the students with elevated health anxiety. Marcus et al. (2007) indicated that Marcus's

(1999) priming task was more indirect and subtle than the one used by Lecci and Cohen

(2002), but they felt the inconsistent results could also be due to the very different

dependent variables that were used in each study (i.e., Stroop interference versus self-

21

reported state anxiety). Marcus et al. (2007) stated that because there were only three

published studies and the findings from these studies were not consistent, they felt it was

not appropriate to perform a meta-analysis on the triggers component. Given that the

findings were not consistent, Marcus et al. (2007) also state that if health anxious

concerns are better conceptualized as chronic concerns instead of dormant cognitive

contents triggered by certain events as hypothesised in the CB model, then health anxiety

may be better conceptualized as an ongoing state of mind rather than a discreet series of

events.

Studies of Perception and Amplification of Bodily Sensations. A final area that

was examined by Marcus et al. (2007) was the extent to which physiological reactions,

including heightened experience of bodily sensations, maintain health anxiety. This part

of the CB model predicts that heightened levels of anxiety about health will generally

lead to physiological arousal as part of the normal reaction to stress (Salkovskis &

Warwick, 2001). The combination of increased physiological arousal and the health

anxious person's tendency to monitor and misinterpret bodily sensations is predicted to

lead to more anxiety and thus more symptoms, resulting in a vicious cycle of symptoms,

catastrophic misinterpretations, and anxiety (Salkovskis & Warwick, 2001). In support

of this aspect of the model, studies have examined the relationship between health

anxiety and scores on the Somatosensory Amplification Scale (SSAS; Barsky et al.,

1990c), a self-report scale that assesses sensitivity to bodily sensations. Generally, SSAS

scores have been moderately positively correlated with self-reported health anxiety scores

22

reported state anxiety). Marcus et al. (2007) stated that because there were only three

published studies and the findings from these studies were not consistent, they felt it was

not appropriate to perform a meta-analysis on the triggers component. Given that the

findings were not consistent, Marcus et al. (2007) also state that if health anxious

concerns are better conceptualized as chronic concerns instead of dormant cognitive

contents triggered by certain events as hypothesised in the CB model, then health anxiety

may be better conceptualized as an ongoing state of mind rather than a discreet series of

events.

Studies of Perception and Amplification of Bodily Sensations. A final area that

was examined by Marcus et al. (2007) was the extent to which physiological reactions,

including heightened experience of bodily sensations, maintain health anxiety. This part

of the CB model predicts that heightened levels of anxiety about health will generally

lead to physiological arousal as part of the normal reaction to stress (Salkovskis &

Warwick, 2001). The combination of increased physiological arousal and the health

anxious person's tendency to monitor and misinterpret bodily sensations is predicted to

lead to more anxiety and thus more symptoms, resulting in a vicious cycle of symptoms,

catastrophic misinterpretations, and anxiety (Salkovskis & Warwick, 2001). In support

of this aspect of the model, studies have examined the relationship between health

anxiety and scores on the Somatosensory Amplification Scale (SSAS; Barsky et al.,

1990c), a self-report scale that assesses sensitivity to bodily sensations. Generally, SSAS

scores have been moderately positively correlated with self-reported health anxiety scores

22

(Barsky & Wyshak, 1990) and medical patients diagnosed with hypochondriasis score

higher on the SSAS than do other medical patients (Barsky et al., 1990c).

Other studies have used in vivo procedures to examine whether individuals with

elevated health anxiety are in fact more sensitive to physical sensations or more accurate

in their perceptions of bodily processes. In this case, women with high levels of health

anxiety have been found to evidence greater pain sensitivity on a cold pressor task (i.e.,

they rated the task as more unpleasant, withdrew their hands more quickly, and had a

greater elevation in heart rate) than women with lower levels of health anxiety (Gramling,

Clawson, & McDonald, 1996). However, despite higher SSAS scores, patients with

elevated health anxiety have not been found to be more accurate on a heartbeat detection

task than patients without elevated health anxiety. In fact, in this research, there was a

trend toward greater accuracy among the patients without elevated health anxiety (Barsky

et al., 1995). Similarly, Haenen, Schmidt, Schoenmakers, and van der Hout (1996) found

that although patients with a diagnosis of hypochondriasis had higher SSAS scores, they

were no more sensitive to tactile stimuli (assessed with a two two-point discrimination

task) than a control group of healthy adults. Marcus et al. (2007) have interpreted the

findings to indicate health anxiety is probably not related to increased physical sensations

per se, but rather to increased misinterpretations of sensations. Overall, Marcus et al.

(2007) concluded that the results of their meta-analysis suggest that the CB model holds

significant promise.

Other Maintaining Factors. As described above, within the CB model, safety-

seeking behaviours, such as avoidance, checking, and reassurance seeking are similarly

23

(Barsky & Wyshak, 1990) and medical patients diagnosed with hypochondriasis score

higher on the SSAS than do other medical patients (Barsky et al., 1990c).

Other studies have used in vivo procedures to examine whether individuals with

elevated health anxiety are in fact more sensitive to physical sensations or more accurate

in their perceptions of bodily processes. In this case, women with high levels of health

anxiety have been found to evidence greater pain sensitivity on a cold pressor task (i.e.,

they rated the task as more unpleasant, withdrew their hands more quickly, and had a

greater elevation in heart rate) than women with lower levels of health anxiety (Gramling,

Clawson, & McDonald, 1996). However, despite higher SSAS scores, patients with

elevated health anxiety have not been found to be more accurate on a heartbeat detection

task than patients without elevated health anxiety. In fact, in this research, there was a

trend toward greater accuracy among the patients without elevated health anxiety (Barsky

et al., 1995). Similarly, Haenen, Schmidt, Schoenmakers, and van der Hout (1996) found

that although patients with a diagnosis of hypochondriasis had higher SSAS scores, they

were no more sensitive to tactile stimuli (assessed with a two two-point discrimination

task) than a control group of healthy adults. Marcus et al. (2007) have interpreted the

findings to indicate health anxiety is probably not related to increased physical sensations

per se, but rather to increased misinterpretations of sensations. Overall, Marcus et al.

(2007) concluded that the results of their meta-analysis suggest that the CB model holds

significant promise.

Other Maintaining Factors. As described above, within the CB model, safety-

seeking behaviours, such as avoidance, checking, and reassurance seeking are similarly

23

hypothesized to maintain health anxiety (Salkovskis & Warwick, 2001). When a person

tries to avoid or check for physical disease (e.g., avoiding strenuous exercise or contact

with disease; reading medical information from the Internet; frequently consulting with

physicians; bodily checking, manipulation, and inspection) this is expected to sustain

anxiety by increasing symptoms that form the focus of the misinterpretation.

Seeking reassurance from medical professionals, family, or friends is

hypothesized to increase health anxiety and worry through an increase in the likelihood

that the individual with elevated health anxiety will receive ambiguous or false positive

results of medical tests, and through inconsistencies in the information given by different

people on different occasions. Safety-seeking behaviour is thought to have a significant

effect on the maintenance of health anxiety when the individual believes that his or her

safety-seeking behaviour has the immediate and direct effect of preventing the health-

related problem. When this occurs, the person experiences short-term relief because he

or she feels safe. However, the individual also gains no evidence to disconfirm erroneous

assumptions.

In support of this aspect of the model, researchers have found that individuals

with elevated levels of health anxiety respond less positively to information typically

interpreted as reassuring. Lucock, Morley, White, and Peake (1997) found that

reassurance, even when initially effective, does not remain effective in the long-term.

After 49 out of 50 patients, who underwent a gastroscopy, had their physician

consultation, negative diagnostic findings led to an immediate feeling of reassurance

(Lucock et al., 1997). However, when these patients were separated into three groups

24

hypothesized to maintain health anxiety (Salkovskis & Warwick, 2001). When a person

tries to avoid or check for physical disease (e.g., avoiding strenuous exercise or contact

with disease; reading medical information from the Internet; frequently consulting with

physicians; bodily checking, manipulation, and inspection) this is expected to sustain

anxiety by increasing symptoms that form the focus of the misinterpretation.

Seeking reassurance from medical professionals, family, or friends is

hypothesized to increase health anxiety and worry through an increase in the likelihood

that the individual with elevated health anxiety will receive ambiguous or false positive

results of medical tests, and through inconsistencies in the information given by different

people on different occasions. Safety-seeking behaviour is thought to have a significant

effect on the maintenance of health anxiety when the individual believes that his or her

safety-seeking behaviour has the immediate and direct effect of preventing the health-

related problem. When this occurs, the person experiences short-term relief because he

or she feels safe. However, the individual also gains no evidence to disconfirm erroneous

assumptions.

In support of this aspect of the model, researchers have found that individuals

with elevated levels of health anxiety respond less positively to information typically

interpreted as reassuring. Lucock, Morley, White, and Peake (1997) found that

reassurance, even when initially effective, does not remain effective in the long-term.

After 49 out of 50 patients, who underwent a gastroscopy, had their physician

consultation, negative diagnostic findings led to an immediate feeling of reassurance

(Lucock et al., 1997). However, when these patients were separated into three groups

24

based on their levels of health anxiety (as assessed by the IAS), individuals with the

highest levels of health anxiety no longer felt reassured 24 hours following the

consultation. In fact, their level of worry about their health and illness conviction

returned to levels equal to those found prior to receiving their test results. At one-year

follow-up, the group with the highest levels of health anxiety continued to be concerned

about their symptoms.

Individuals with elevated levels of health anxiety have also been found to be

significantly more likely to immediately interpret health information provided by their

physician as less reassuring than the physicians had perceived their feedback to be

(Lucock, White, Peake, & Morley, 1998). When measured again at one-month follow-

up, patient reassurance ratings were found to have decreased further. Similarly,

individuals with moderate levels of health anxiety rated the level of reassurance provided

by their physician lower after one month had elapsed.

Another maintaining factor in health anxiety is affect, particularly anxiety and

depression (Salkovskis & Warwick, 2001). For instance, mood disturbances have been

linked to negative or maladaptive patterns of thinking, which then leads to further

increases in mood disturbance (Salkovskis & Warwick, 2001). These cognitive processes

in anxiety and depression generally are thought to prime ruminative worries about health

problems and the implications of the feared consequences (Salkovskis & Warwick,

2001).

25

based on their levels of health anxiety (as assessed by the IAS), individuals with the

highest levels of health anxiety no longer felt reassured 24 hours following the

consultation. In fact, their level of worry about their health and illness conviction

returned to levels equal to those found prior to receiving their test results. At one-year

follow-up, the group with the highest levels of health anxiety continued to be concerned

about their symptoms.

Individuals with elevated levels of health anxiety have also been found to be

significantly more likely to immediately interpret health information provided by their

physician as less reassuring than the physicians had perceived their feedback to be

(Lucock, White, Peake, & Morley, 1998). When measured again at one-month follow-

up, patient reassurance ratings were found to have decreased further. Similarly,

individuals with moderate levels of health anxiety rated the level of reassurance provided

by their physician lower after one month had elapsed.

Another maintaining factor in health anxiety is affect, particularly anxiety and

depression (Salkovskis & Warwick, 2001). For instance, mood disturbances have been

linked to negative or maladaptive patterns of thinking, which then leads to further

increases in mood disturbance (Salkovskis & Warwick, 2001). These cognitive processes

in anxiety and depression generally are thought to prime ruminative worries about health

problems and the implications of the feared consequences (Salkovskis & Warwick,

2001).

25

1.5 Health Anxiety Among Seniors

There is a commonly held belief that older adults display greater health-related

concerns compared with younger adults (Snyder & Stanley, 2001). Factors associated

with aging, such as higher rates of medical illness, physical frailty, and a heightened

sense of mortality, may contribute to excessive preoccupation with health-related issues

(Snyder & Stanley, 2001). Available prevalence estimates of hypochondriasis from older

community samples range from 3.9% to 33.0% (Palmore, 1970; Stenback, Kumpulainen,

& Vauhkenen, 1978) as compared with similar estimates of 4.2% to 13.8% for

hypochondriasis in general medical patients (Barsky, Wyshak, & Klerman, 1990a; Noyes

et al., 1993). Barsky, Frank, Cleary, Wyshak, and Klerman (1991) examined the

relationship between hypochondriasis and age in 60 patients who met the DSM-III-R

diagnostic criteria for hypochondriasis and 100 comparison patients from a general

medical clinic. Barsky, Frank, Cleary, et al. (1991) concluded that hypochondriasis is

found to some degree in all patients and appeared to be unrelated to age. They also found

that patients with hypochondriasis aged 65 years and over did not differ significantly

from younger patients with hypochondriasis in hypochondriacal attitudes, somatization,

tendency to amplify bodily sensation, or global assessment of their overall health, even

though they had higher level of physical difficulties. A non-significant trend was noted

in that the older adult group endorsed less disease anxiety and disease conviction when

compared with the younger patients. When examining the social and functional activity

levels of participants, older patients reported greater difficulty participating in social

events and activities of daily living than younger patients. This decline in functioning

26

1.5 Health Anxiety Among Seniors

There is a commonly held belief that older adults display greater health-related

concerns compared with younger adults (Snyder & Stanley, 2001). Factors associated

with aging, such as higher rates of medical illness, physical frailty, and a heightened

sense of mortality, may contribute to excessive preoccupation with health-related issues

(Snyder & Stanley, 2001). Available prevalence estimates of hypochondriasis from older

community samples range from 3.9% to 33.0%> (Palmore, 1970; Stenback, Kumpulainen,

& Vauhkenen, 1978) as compared with similar estimates of 4.2% to 13.8% for

hypochondriasis in general medical patients (Barsky, Wyshak, & Klerman, 1990a; Noyes

et al., 1993). Barsky, Frank, Cleary, Wyshak, and Klerman (1991) examined the

relationship between hypochondriasis and age in 60 patients who met the DSM-III-R

diagnostic criteria for hypochondriasis and 100 comparison patients from a general

medical clinic. Barsky, Frank, Cleary, et al. (1991) concluded that hypochondriasis is

found to some degree in all patients and appeared to be unrelated to age. They also found

that patients with hypochondriasis aged 65 years and over did not differ significantly

from younger patients with hypochondriasis in hypochondriacal attitudes, somatization,

tendency to amplify bodily sensation, or global assessment of their overall health, even

though they had higher level of physical difficulties. A non-significant trend was noted

in that the older adult group endorsed less disease anxiety and disease conviction when

compared with the younger patients. When examining the social and functional activity

levels of participants, older patients reported greater difficulty participating in social

events and activities of daily living than younger patients. This decline in functioning

26

with age was not observed in the comparison group, despite similar medical morbidity.

Snyder and Stanley (2001) suggest that older patients with hypochondriasis are less

functional than younger patients despite similarities in hypochondriacal symptoms, and

that severe health anxiety may be more incapacitating in older adults even when symptom

severity is similar to that of younger patients.

Bourgault-Fagnou and Hadjistavropoulos (2009) examined predictors of health

anxiety in a sample of older adults with varying levels of frailty receiving home health

care services using a medically adjusted version of the IAS. Frailty is conceptualized as a

multidimensional, heterogeneous, and unstable state of vulnerability for mortality and

morbidity (distinguishing it from disability or aging alone) (Hogan, MacKnight, &

Bergman, 2003). The score on the medically adjusted version of the IAS was calculated

by summing items that reflected worry about illness, anxiety about health, and bodily

preoccupation, as well as items that were not confounded by whether the individual was

suffering from an illness. Using mediation analysis, Bourgault-Fagnou and

Hadjistavropoulos (2009) found that emotional preoccupation coping mediated the

relationship between frailty and health anxiety, which they felt suggested that frailty

alone may not necessarily lead to health anxiety. Instead, frailty seemed to be associated

with emotional preoccupation coping which then fully accounted for its relationship with

health anxiety among older adults.

Similarly, Boston and Merrick (2010) examined health anxiety among 145 older

adults recruited from community-based organizations and retirement village communities

in Australia. Using the Short Health Anxiety Inventory (SHAI; Salkovskis, Rimes,

27

with age was not observed in the comparison group, despite similar medical morbidity.

Snyder and Stanley (2001) suggest that older patients with hypochondriasis are less

functional than younger patients despite similarities in hypochondriacal symptoms, and

that severe health anxiety may be more incapacitating in older adults even when symptom

severity is similar to that of younger patients.

Bourgault-Fagnou and Hadjistavropoulos (2009) examined predictors of health

anxiety in a sample of older adults with varying levels of frailty receiving home health

care services using a medically adjusted version of the IAS. Frailty is conceptualized as a

multidimensional, heterogeneous, and unstable state of vulnerability for mortality and

morbidity (distinguishing it from disability or aging alone) (Hogan, MacKnight, &

Bergman, 2003). The score on the medically adjusted version of the IAS was calculated

by summing items that reflected worry about illness, anxiety about health, and bodily

preoccupation, as well as items that were not confounded by whether the individual was

suffering from an illness. Using mediation analysis, Bourgault-Fagnou and

Hadjistavropoulos (2009) found that emotional preoccupation coping mediated the

relationship between frailty and health anxiety, which they felt suggested that frailty

alone may not necessarily lead to health anxiety. Instead, frailty seemed to be associated

with emotional preoccupation coping which then fully accounted for its relationship with

health anxiety among older adults.

Similarly, Boston and Merrick (2010) examined health anxiety among 145 older

adults recruited from community-based organizations and retirement village communities

in Australia. Using the Short Health Anxiety Inventory (SHAI; Salkovskis, Rimes,

27

Warwick, & Clark, 2002), approximately 7.6% of participants reported scores of 15 or

higher, indicating acute health anxiety (Rode, Salkovskis, Dowd, & Hanna, 2006). The

majority of the group also reported some physical illness. The authors indicated that the

SHAI scores for this group were similar to those reported in other studies for younger

people with chronic illness (Abramowitz, Deacon, & Valentiner, 2007; Rode et al., 2006;

Salkovskis et al., 2002).

Given the findings by Boston and Merrick (2010) described above, research

examining the prevalence of health anxiety among younger individuals with chronic

health conditions was examined. Research in this area is limited as only three studies

have addressed this topic area. Rode et al. (2006) assessed health anxiety in individuals

referred to a specialist chronic pain clinic using the SHAI. Severe and persistent health

anxiety was identified in 37% of these participants. Similar to this, Grassi, Sabato, Rossi,

Biancosino, and Marmai (2005) used the Diagnostic Criteria for Psychosomatic Research

System (Fava et al., 1995) to assess 146 patients with cancer for psychiatric morbidity

and psychosocial syndromes. They found that approximately 38% of mixed cancer

patients experienced persistent health anxiety. In contrast, using the SHAI, lower rates of

health anxiety were found among 246 individuals with multiple sclerosis, with

approximately 25% reporting severe and persistent health anxiety (Kehler &

Hadjistavropoulos, 2008). The findings suggest that health anxiety is substantial among

individuals with chronic health conditions, but also that variability may exist in the

prevalence of health anxiety depending on the chronic health condition examined.

28

Warwick, & Clark, 2002), approximately 7.6% of participants reported scores of 15 or

higher, indicating acute health anxiety (Rode, Salkovskis, Dowd, & Hanna, 2006). The

majority of the group also reported some physical illness. The authors indicated that the

SHAI scores for this group were similar to those reported in other studies for younger

people with chronic illness (Abramowitz, Deacon, & Valentiner, 2007; Rode et al., 2006;

Salkovskis et al , 2002).

Given the findings by Boston and Merrick (2010) described above, research

examining the prevalence of health anxiety among younger individuals with chronic

health conditions was examined. Research in this area is limited as only three studies

have addressed this topic area. Rode et al. (2006) assessed health anxiety in individuals

referred to a specialist chronic pain clinic using the SHAI. Severe and persistent health

anxiety was identified in 37% of these participants. Similar to this, Grassi, Sabato, Rossi,

Biancosino, and Marmai (2005) used the Diagnostic Criteria for Psychosomatic Research

System (Fava et al., 1995) to assess 146 patients with cancer for psychiatric morbidity

and psychosocial syndromes. They found that approximately 38% of mixed cancer

patients experienced persistent health anxiety. In contrast, using the SHAI, lower rates of

health anxiety were found among 246 individuals with multiple sclerosis, with

approximately 25% reporting severe and persistent health anxiety (Kehler &

Hadjistavropoulos, 2008). The findings suggest that health anxiety is substantial among

individuals with chronic health conditions, but also that variability may exist in the

prevalence of health anxiety depending on the chronic health condition examined.

28

These findings suggest that elevated health anxiety may not be part of the normal

experience for seniors, even when a health condition is present. However, although

health anxiety appears to occur less in older adults when compared to younger adults, it is

still a concern for a number of individuals. Given the limited research on health anxiety

among older adults, the following sections outline the CB model as it applies to older

persons and research on other specific forms of anxiety that affect seniors.

1.5.1 How Does the Cognitive Behavioural Model of Health Anxiety Apply to Older

Adults?

Boston and Merrick (2010) and Snyder and Stanley (2001) indicate that the CB

model of health anxiety may be applicable to older adults. First, the CB model posits that

innocuous bodily sensations are misinterpreted as a serious threat to health or a sign of

illness (Salkovskis & Warwick, 2001). There are a number of factors associated with

aging, such as increased somatic changes, decreased physical agility, greater medical

morbidity, and greater physical frailty that may cause an older adult to focus his or her

attention to health and bodily sensations (Barsky, 1993; Snyder & Stanley), and possibly

increase the chance of misinterpretation.

Second, certain common experiences seniors encounter during later life may serve

as critical incidents in the emergence of health-related anxiety (Snyder & Stanley, 2001).

For instance, older adults are likely to experience a higher number of health-related

distressing events, including the illness or death of a spouse, family member, or friend,

disease themselves, and falls or bodily injuries. The physiological changes associated

with aging may intensify difficulties seniors have coping with health anxiety (Snyder &

29

These findings suggest that elevated health anxiety may not be part of the normal

experience for seniors, even when a health condition is present. However, although

health anxiety appears to occur less in older adults when compared to younger adults, it is

still a concern for a number of individuals. Given the limited research on health anxiety

among older adults, the following sections outline the CB model as it applies to older

persons and research on other specific forms of anxiety that affect seniors.

1.5.1 How Does the Cognitive Behavioural Model of Health Anxiety Apply to Older

Adults?

Boston and Merrick (2010) and Snyder and Stanley (2001) indicate that the CB

model of health anxiety may be applicable to older adults. First, the CB model posits that

innocuous bodily sensations are misinterpreted as a serious threat to health or a sign of

illness (Salkovskis & Warwick, 2001). There are a number of factors associated with

aging, such as increased somatic changes, decreased physical agility, greater medical

morbidity, and greater physical frailty that may cause an older adult to focus his or her

attention to health and bodily sensations (Barsky, 1993; Snyder & Stanley), and possibly

increase the chance of misinterpretation.

Second, certain common experiences seniors encounter during later life may serve

as critical incidents in the emergence of health-related anxiety (Snyder & Stanley, 2001).

For instance, older adults are likely to experience a higher number of health-related

distressing events, including the illness or death of a spouse, family member, or friend,

disease themselves, and falls or bodily injuries. The physiological changes associated

with aging may intensify difficulties seniors have coping with health anxiety (Snyder &

29

Stanley, 2001). That is, given that older adults experience greater frailty and disease, this

may intensify pre-existing health anxiety or decrease perceived ability to function in

people with pre-existing health anxiety.

Third, Boston and Merrick (2010) suggest that older people have developed

coping behaviours throughout their lives. Although for most people these coping

behaviours are adaptive, in some more vulnerable people they may develop into

problematic safety-seeking behaviours which serve to reinforce and maintain health

anxiety (Snyder and Stanley, 2001). In addition, it is possible that decreasing physical

function and cognitive decline may render coping mechanisms less effective (Boston &

Merrick, 2010).

Only one study has empirically tested the applicability of aspects of the CB model

of health anxiety to older adults. Boston and Merrick (2010) found that, consistent with

the CB model of health anxiety, health anxiety as measured by the SHAI predicted safety

behaviours and medical utilization in a community sample of 145 older adults in

Australia. Boston and Merrick (2010) concluded that the findings of this study were a

step towards empirical support for the applicability of the CB model of health anxiety to

older adults.

1.6 Other Forms of Anxiety Among Seniors

1.6.1 Symptoms of Anxiety: Trait and State Anxiety

As outlined above, anxiety disorders affect a significant number of older adults.

Rates of anxiety are also significant when sub-clinical levels of anxiety are assessed in

older adults. For example, in a survey of community dwelling elders, Himmelfarb and

30

Stanley, 2001). That is, given that older adults experience greater frailty and disease, this

may intensify pre-existing health anxiety or decrease perceived ability to function in

people with pre-existing health anxiety.

Third, Boston and Merrick (2010) suggest that older people have developed

coping behaviours throughout their lives. Although for most people these coping

behaviours are adaptive, in some more vulnerable people they may develop into

problematic safety-seeking behaviours which serve to reinforce and maintain health

anxiety (Snyder and Stanley, 2001). In addition, it is possible that decreasing physical

function and cognitive decline may render coping mechanisms less effective (Boston &

Merrick, 2010).

Only one study has empirically tested the applicability of aspects of the CB model

of health anxiety to older adults. Boston and Merrick (2010) found that, consistent with

the CB model of health anxiety, health anxiety as measured by the SHAI predicted safety

behaviours and medical utilization in a community sample of 145 older adults in

Australia. Boston and Merrick (2010) concluded that the findings of this study were a

step towards empirical support for the applicability of the CB model of health anxiety to

older adults.

1.6 Other Forms of Anxiety Among Seniors

1.6.1 Symptoms of Anxiety: Trait and State Anxiety

As outlined above, anxiety disorders affect a significant number of older adults.

Rates of anxiety are also significant when sub-clinical levels of anxiety are assessed in

older adults. For example, in a survey of community dwelling elders, Himmelfarb and

30

Murrell (1984) found that 17% of males and 21% of females experienced anxiety

symptoms of sufficient severity to warrant intervention. When using the STAI

(Spielberger, 1983) in a sample of 73 geriatric inpatients, Kvaal, Macijauskiene, Engedal,

and Laake (2001) found that 41% of the female patients and 47% of the male patients had

a STAI state scale score above the cut-off of 39-40 points for significant anxiety

symptoms (Kvaal et al., 2001). In a follow-up study with the same patients, it was found

that the score on the STAI state scale had increased one to three months after discharge

(Kvaal & Laake, 2003). Bourgault-Fagnou and Hadjistavropoulos (2009) examined

levels of trait anxiety in a sample of 112 seniors receiving home care services. The

sample was classified into a low-frailty group and a high-frailty group. The authors

found that the low-frailty group was experiencing average levels of trait anxiety

(compared with a normative sample; Spielberger et al., 1983). However, they also found

that the group classified as being high-frailty was experiencing above-average levels of

trait anxiety (compared with a normative sample; Spielberger et al., 1983), suggesting

higher levels of trait anxiety among those individuals with poorer health.

Trait and state anxiety and health anxiety are similar, yet distinct concepts. Trait

anxiety is described as a relatively enduring predisposition to respond to stress with

anxiety, along with a tendency to view a broad range of situations as potentially

threatening (Nixon & Steffeck, 1977). State anxiety, however, can be described as one's

current subjective experience of apprehension and arousal of the autonomic system in

response to stress (Nixon & Steffeck, 1977). In hypothesized hierarchical fear structures,

trait anxiety is situated at one of the higher levels, whereas more specific fears are lower

31

Murrell (1984) found that 17% of males and 21% of females experienced anxiety

symptoms of sufficient severity to warrant intervention. When using the STAI

(Spielberger, 1983) in a sample of 73 geriatric inpatients, Kvaal, Macijauskiene, Engedal,

and Laake (2001) found that 41% of the female patients and 47% of the male patients had

a STAI state scale score above the cut-off of 39-40 points for significant anxiety

symptoms (Kvaal et al., 2001). In a follow-up study with the same patients, it was found

that the score on the STAI state scale had increased one to three months after discharge

(Kvaal & Laake, 2003). Bourgault-Fagnou and Hadjistavropoulos (2009) examined

levels of trait anxiety in a sample of 112 seniors receiving home care services. The

sample was classified into a low-frailty group and a high-frailty group. The authors

found that the low-frailty group was experiencing average levels of trait anxiety

(compared with a normative sample; Spielberger et al., 1983). However, they also found

that the group classified as being high-frailty was experiencing above-average levels of

trait anxiety (compared with a normative sample; Spielberger et al., 1983), suggesting

higher levels of trait anxiety among those individuals with poorer health.

Trait and state anxiety and health anxiety are similar, yet distinct concepts. Trait

anxiety is described as a relatively enduring predisposition to respond to stress with

anxiety, along with a tendency to view a broad range of situations as potentially

threatening (Nixon & Steffeck, 1977). State anxiety, however, can be described as one's

current subjective experience of apprehension and arousal of the autonomic system in

response to stress (Nixon & Steffeck, 1977). In hypothesized hierarchical fear structures,

trait anxiety is situated at one of the higher levels, whereas more specific fears are lower

31

order factors (Taylor, 1995; Zinbarg, Barlow, & Brown, 1997). Researchers have found

a moderate correlation between trait anxiety and health anxiety, but suggest that they

remain distinct constructs (Bourgault-Fagnou & Hadjistavropoulos, 2009; Hitchcock &

Mathews, 1992; Stewart & Watt, 2000).

1.6.2 Anxiety Sensitivity

Due to the increased attention paid to bodily sensations among those with

elevated health anxiety, anxiety sensitivity may be another important construct associated

with health anxiety in older adults. Anxiety sensitivity is an individual's tendency to fear

his or her own anxiety and anxiety-related symptoms because such symptoms are

believed to have harmful consequences (Reiss & McNally, 1985). Anxiety sensitivity is

believed to be a stable, trait-like characteristic and has been described as a risk factor for

anxiety-related disorders such as panic disorder (Schmidt & Joiner, 2002). It is

considered to be a dimensional construct consisting of three distinct, but related,

dimensions including physical concerns (i.e., fear of negative physical consequences of

anxiety-related somatic sensations), mental incapacitation (i.e., fear of negative

psychological consequences of anxiety-related cognitive sensations), and social concerns

(i.e., fear of negative social consequences of publicly observable anxiety sensations)

(Zinbarg, Mohlman, & Hong, 1999).

Anxiety sensitivity has been shown to be a significant predictor, albeit a separate

and distinct construct, of health anxiety in clinical (Otto, Demopulos, McLean, Pollack,

& Fava, 1998; Otto, Pollack, Sachs, & Rosenbaum, 1992) and non-clinical samples

(Stewart & Watt, 2000). Recently, Olatunji, Wolitzky-Taylor, Elwood, Connolly,

32

order factors (Taylor, 1995; Zinbarg, Barlow, & Brown, 1997). Researchers have found

a moderate correlation between trait anxiety and health anxiety, but suggest that they

remain distinct constructs (Bourgault-Fagnou & Hadjistavropoulos, 2009; Hitchcock &

Mathews, 1992; Stewart & Watt, 2000).

1.6.2 Anxiety Sensitivity

Due to the increased attention paid to bodily sensations among those with

elevated health anxiety, anxiety sensitivity may be another important construct associated

with health anxiety in older adults. Anxiety sensitivity is an individual's tendency to fear

his or her own anxiety and anxiety-related symptoms because such symptoms are

believed to have harmful consequences (Reiss & McNally, 1985). Anxiety sensitivity is

believed to be a stable, trait-like characteristic and has been described as a risk factor for

anxiety-related disorders such as panic disorder (Schmidt & Joiner, 2002). It is

considered to be a dimensional construct consisting of three distinct, but related,

dimensions including physical concerns (i.e., fear of negative physical consequences of

anxiety-related somatic sensations), mental incapacitation (i.e., fear of negative

psychological consequences of anxiety-related cognitive sensations), and social concerns

(i.e., fear of negative social consequences of publicly observable anxiety sensations)

(Zinbarg, Mohlman, & Hong, 1999).

Anxiety sensitivity has been shown to be a significant predictor, albeit a separate

and distinct construct, of health anxiety in clinical (Otto, Demopulos, McLean, Pollack,

& Fava, 1998; Otto, Pollack, Sachs, & Rosenbaum, 1992) and non-clinical samples

(Stewart & Watt, 2000). Recently, Olatunji, Wolitzky-Taylor, Elwood, Connolly,

32

Gonzales, and Armstrong (2009) confirmed a relationship between anxiety sensitivity and

symptoms of health anxiety. More specifically, Olatunji et al. (2009) found that the

anxiety sensitivity dimension of physical concerns had the largest relationship with health

anxiety, particularly illness likelihood and body vigilance aspects of health anxiety (as

measured by the SHAI).

With respect to the older adult population, Bravo and Silverman (2001) examined

the role of anxiety sensitivity, anxiety, and depression in 53 clinic referred (i.e.,

outpatient mental health programs) and 53 non-clinic referred older adults and their

relation to hypochondriacal concerns and medical illnesses. The results indicated that

anxiety sensitivity was significantly elevated in the clinic-referred group relative to the

non-clinic referred group, was negatively associated with a history of medical illnesses,

was strongly associated with health anxious concerns, and was a better predictor of health

anxious concerns than depression and trait anxiety.

1.7 Depression and Its Relationship to Health Anxiety in Seniors

Depression is one of the most common psychiatric disorders diagnosed in seniors

(Blazer, 1998; Hawranik, 1991). In the general population, approximately 10% to 15%

of seniors request help or require intervention for depressive complaints (Brodarty, 1993;

Beekman, Deeg, Braam, Smit, & van Tilburg, 1997). Because of this high rate of

depression among older adults, it is important to consider its relationship with health

anxiety. Symptoms of health anxiety have been found to be prevalent among seniors

with depression (Blazer, 1998). Koenig, Cohen, Blazer, Krishnan, and Sibert (1993)

examined the profile of depressive symptoms in younger and older male medical

33

Gonzales, and Armstrong (2009) confirmed a relationship between anxiety sensitivity and

symptoms of health anxiety. More specifically, Olatunji et al. (2009) found that the

anxiety sensitivity dimension of physical concerns had the largest relationship with health

anxiety, particularly illness likelihood and body vigilance aspects of health anxiety (as

measured by the SHAI).

With respect to the older adult population, Bravo and Silverman (2001) examined

the role of anxiety sensitivity, anxiety, and depression in 53 clinic referred (i.e.,

outpatient mental health programs) and 53 non-clinic referred older adults and their

relation to hypochondriacal concerns and medical illnesses. The results indicated that

anxiety sensitivity was significantly elevated in the clinic-referred group relative to the

non-clinic referred group, was negatively associated with a history of medical illnesses,

was strongly associated with health anxious concerns, and was a better predictor of health

anxious concerns than depression and trait anxiety.

1.7 Depression and Its Relationship to Health Anxiety in Seniors

Depression is one of the most common psychiatric disorders diagnosed in seniors

(Blazer, 1998; Hawranik, 1991). In the general population, approximately 10% to 15%

of seniors request help or require intervention for depressive complaints (Brodarty, 1993;

Beekman, Deeg, Braam, Smit, & van Tilburg, 1997). Because of this high rate of

depression among older adults, it is important to consider its relationship with health

anxiety. Symptoms of health anxiety have been found to be prevalent among seniors

with depression (Blazer, 1998). Koenig, Cohen, Blazer, Krishnan, and Sibert (1993)

examined the profile of depressive symptoms in younger and older male medical

33

inpatients aged 20-39 years (n = 116) and aged 70-102 years (n = 332), consecutively

admitted to the medical and neurological services of a medical centre. They found that,

among older men, loss of interest, insomnia, suicidal thoughts, and somatic concerns

most strongly differentiated depressed from non-depressed patients. Lyness, King,

Conwell, Cox, and Caine (1993) found that increasing age and depressive

symptomatology were predictors of greater somatic concern in 109 psychiatric inpatients

with DSM-III-R major depression. More recently, Bourgault-Fagnou and

Hadjistavropoulos (2009) examined predictors of health anxiety in sample of 112 seniors

receiving home care services. The authors found that higher levels of depression, along

with higher levels of pain, frailty, trait anxiety, and emotional preoccupation coping,

predicted higher health anxiety as measured by the IAS.

1.8 Treatment Issues

1.8.1 Treatment of Health Anxiety

Treatment provided under the CB orientation involves helping the individual with

health anxiety see that what they believe to be health-threatening symptoms can

alternatively be the result of normal bodily functioning (Warwick, 1989). CBT can also

assist the person in developing an understanding of bodily sensations and effective ways

of coping with preoccupation with bodily symptoms. As psychologically-oriented

treatment may be seen as potentially threatening in and of itself, and, as health problems

may be ignored and, in the meantime, worsen, it is important to point out the benefits of

this approach (Warwick, 1989).

34

inpatients aged 20-39 years (n = 116) and aged 70-102 years (n = 332), consecutively

admitted to the medical and neurological services of a medical centre. They found that,

among older men, loss of interest, insomnia, suicidal thoughts, and somatic concerns

most strongly differentiated depressed from non-depressed patients. Lyness, King,

Conwell, Cox, and Caine (1993) found that increasing age and depressive

symptomatology were predictors of greater somatic concern in 109 psychiatric inpatients

with DSM-III-R major depression. More recently, Bourgault-Fagnou and

Hadjistavropoulos (2009) examined predictors of health anxiety in sample of 112 seniors

receiving home care services. The authors found that higher levels of depression, along

with higher levels of pain, frailty, trait anxiety, and emotional preoccupation coping,

predicted higher health anxiety as measured by the IAS.

1.8 Treatment Issues

1.8.1 Treatment of Health Anxiety

Treatment provided under the CB orientation involves helping the individual with

health anxiety see that what they believe to be health-threatening symptoms can

alternatively be the result of normal bodily functioning (Warwick, 1989). CBT can also

assist the person in developing an understanding of bodily sensations and effective ways

of coping with preoccupation with bodily symptoms. As psychologically-oriented

treatment may be seen as potentially threatening in and of itself, and, as health problems

may be ignored and, in the meantime, worsen, it is important to point out the benefits of

this approach (Warwick, 1989).

34

Taylor and Asmundson (2004) outline several interventions used in CBT for

health anxiety to help the person abandon dysfunctional beliefs and accept more adaptive

ways of thinking about health and disease. CBT for health anxiety generally includes the

following strategies: treatment engagement strategies, psychoeducation, goal setting,

cognitive restructuring, behavioural exercises, stress management techniques, and relapse

prevention methods (Taylor & Asmundson, 2004).

Treatment engagement strategies are used to enhance treatment motivation and

encourage more adaptive ways of thinking about health and disease. For example, the

therapist may use motivational interviewing techniques (MI; Miller & Rollnick, 2002)

such as open-ended questions, reflective listening, summary statements, and differential

reinforcement of the patient's utterances in order to elicit self-motivating statements from

the patient and to decrease the patient's reluctance to engage fully in therapy.

Psychoeducation involves providing alternative, noncatastrophic explanations of

the patient's bodily changes or sensations. Explanations should include both

physiological and psychological explanations in order to help the patient understand that

their symptoms are real, and a result of normal bodily processes (Sharpe, Bass, & Mayou,

1995). The explanation should also discuss how beliefs, emotions, and bodily changes

and sensations are interrelated (Smith, 1985).

The patient and therapist may also work together to develop a set of goals to work

on in the course of therapy. Common treatment goals for health anxiety can include

decreased disease conviction, decreased health-related worry, decreased medical

35

Taylor and Asmundson (2004) outline several interventions used in CBT for

health anxiety to help the person abandon dysfunctional beliefs and accept more adaptive

ways of thinking about health and disease. CBT for health anxiety generally includes the

following strategies: treatment engagement strategies, psychoeducation, goal setting,

cognitive restructuring, behavioural exercises, stress management techniques, and relapse

prevention methods (Taylor & Asmundson, 2004).

Treatment engagement strategies are used to enhance treatment motivation and

encourage more adaptive ways of thinking about health and disease. For example, the

therapist may use motivational interviewing techniques (MI; Miller & Rollnick, 2002)

such as open-ended questions, reflective listening, summary statements, and differential

reinforcement of the patient's utterances in order to elicit self-motivating statements from

the patient and to decrease the patient's reluctance to engage fully in therapy.

Psychoeducation involves providing alternative, noncatastrophic explanations of

the patient's bodily changes or sensations. Explanations should include both

physiological and psychological explanations in order to help the patient understand that

their symptoms are real, and a result of normal bodily processes (Sharpe, Bass, & Mayou,

1995). The explanation should also discuss how beliefs, emotions, and bodily changes

and sensations are interrelated (Smith, 1985).

The patient and therapist may also work together to develop a set of goals to work

on in the course of therapy. Common treatment goals for health anxiety can include

decreased disease conviction, decreased health-related worry, decreased medical

35

utilization, decreased bodily checking, improved health habits, improved overall quality

of life, and so forth (Taylor & Asmundson, 2004).

Cognitive interventions are used to challenge and alter disease-related beliefs.

The aim of cognitive interventions is to promote the development of alternative,

nonthreatening explanations of bodily events (Warwick, 1995). Cognitive interventions

are used to help patients identify and objectively examine their health-related beliefs,

which are usually catastrophic in nature, and to create reasonable, noncatastrophic

alternatives (Taylor & Asmundson, 2004).

Behavioural methods play a large role in treating fear, avoidance, and maladaptive

safety behaviours such as excessive checking and reassurance seeking. Behavioural

exercises generally require the person with health anxiety to be exposed to the feared

stimuli in a systematic, controlled fashion (Taylor & Asmundson, 2004). Behavioural

exercises can include behavioural experiments that test the effects of beliefs and

behaviours (e.g., testing the effects of performing vs. not performing safety behaviours),

situational exposure (i.e., exposure to harmless but fear-evoking stimuli), interoceptive

exposure (i.e., sensation-inducing exercises), and imaginal exposure (e.g., try to imagine

all the components of the feared situation as vividly as possible; Taylor & Asmundson,

2004).

Stress management techniques can be used to reduce a person's anxious arousal.

Typical stress management procedures that are often used to reduce health anxiety

include psychoeducation for stress management, applied relaxation training (e.g.,

36

utilization, decreased bodily checking, improved health habits, improved overall quality

of life, and so forth (Taylor & Asmundson, 2004).

Cognitive interventions are used to challenge and alter disease-related beliefs.

The aim of cognitive interventions is to promote the development of alternative,

nonthreatening explanations of bodily events (Warwick, 1995). Cognitive interventions

are used to help patients identify and objectively examine their health-related beliefs,

which are usually catastrophic in nature, and to create reasonable, noncatastrophic

alternatives (Taylor & Asmundson, 2004).

Behavioural methods play a large role in treating fear, avoidance, and maladaptive

safety behaviours such as excessive checking and reassurance seeking. Behavioural

exercises generally require the person with health anxiety to be exposed to the feared

stimuli in a systematic, controlled fashion (Taylor & Asmundson, 2004). Behavioural

exercises can include behavioural experiments that test the effects of beliefs and

behaviours (e.g., testing the effects of performing vs. not performing safety behaviours),

situational exposure (i.e., exposure to harmless but fear-evoking stimuli), interoceptive

exposure (i.e., sensation-inducing exercises), and imaginal exposure (e.g., try to imagine

all the components of the feared situation as vividly as possible; Taylor & Asmundson,

2004).

Stress management techniques can be used to reduce a person's anxious arousal.

Typical stress management procedures that are often used to reduce health anxiety

include psychoeducation for stress management, applied relaxation training (e.g.,

36

progressive muscle relaxation), breathing retraining, a general approach to problem

solving, and time management techniques (Taylor & Asmundson, 2004).

Relapse prevention methods are used to maintain and extend treatment gains,

including methods for dealing with future episodes of elevated anxiety. A CBT program

for health anxiety should provide the patient with a review of treatment progress, attempt

to establish expectations for post-treatment functioning, provide a written maintenance

plan, outline how to deal with relapse preventions, and, if possible, arrange for periodic

check-ins with the therapist (Taylor & Asmundson, 2004).

Adding to the above description, Furer, Walker, and Freeston (2001) highlight,

several important considerations for the treatment of health anxiety among individuals at

risk for or with chronic medical conditions. First, they highlight the use of problem-

focused coping, such as increasing activities and fully immersing oneself in these

activities in an effort to help to reduce distress. Second, Furer and colleagues suggest that

with slight modifications, many of the core CB techniques may prove beneficial. They

caution that the aim should be to decrease excessive preoccupation with disease and its

negative consequences as opposed to attempting to convince the individual that the

disease and its associated consequences can be avoided. Realistic concern about one's

health is seen as normal, and individuals should be encouraged to be involved in their

health care and to obtain appropriate medical management and tests.

Case studies and several non-randomized controlled studies have been published

on the treatment of elevated health anxiety and hypochondriasis and they suggest that

CBT (6-16 weekly sessions) can effectively reduce health anxiety and hypochondriasis.

37

progressive muscle relaxation), breathing retraining, a general approach to problem

solving, and time management techniques (Taylor & Asmundson, 2004).

Relapse prevention methods are used to maintain and extend treatment gains,

including methods for dealing with future episodes of elevated anxiety. A CBT program

for health anxiety should provide the patient with a review of treatment progress, attempt

to establish expectations for post-treatment functioning, provide a written maintenance

plan, outline how to deal with relapse preventions, and, if possible, arrange for periodic

check-ins with the therapist (Taylor & Asmundson, 2004).

Adding to the above description, Furer, Walker, and Freeston (2001) highlight,

several important considerations for the treatment of health anxiety among individuals at

risk for or with chronic medical conditions. First, they highlight the use of problem-

focused coping, such as increasing activities and fully immersing oneself in these

activities in an effort to help to reduce distress. Second, Furer and colleagues suggest that

with slight modifications, many of the core CB techniques may prove beneficial. They

caution that the aim should be to decrease excessive preoccupation with disease and its

negative consequences as opposed to attempting to convince the individual that the

disease and its associated consequences can be avoided. Realistic concern about one's

health is seen as normal, and individuals should be encouraged to be involved in their

health care and to obtain appropriate medical management and tests.

Case studies and several non-randomized controlled studies have been published

on the treatment of elevated health anxiety and hypochondriasis and they suggest that

CBT (6-16 weekly sessions) can effectively reduce health anxiety and hypochondriasis.

37

For example, Warwick and Marks (1988) evaluated the effectiveness of a CBT for illness

phobia or hypochondriasis with 17 patients with an International Statistical

Classification of Diseases and Related Health Problems 9th Revision (World Health

Organization, 1977) diagnosis. Treatment consisted of seven sessions, on average, during

which exposure and response prevention (i.e., the patient confronts their fears and then

discontinues the usual escape response) was implemented to address avoidance

behaviours (exercise avoidance) and reassurance seeking. Significant improvements

were observed on severity of the patient's main worries (e.g., heart disease), designated

target behaviour(s), vocational and recreational functioning, and on the Fear

Questionnaire (Marks & Mathews, 1979). Treatment gains were maintained for 6 of 13

patients who were followed a median of 5 years.

Bouman and Visser (1998) compared cognitive therapy to behaviour therapy (i.e.,

in vivo exposure plus response prevention) among 17 patients meeting DSM-IV (APA,

1994) criteria for hypochondriasis. Because of the small sample size, patients were used

as their own controls by observing pre- and post-baseline periods of four weeks without

treatment. After the initial interviews, patients were randomly assigned to either of the

two treatment conditions. Patients in both treatment conditions improved on specific

measures of hypochondriasis and depression. The two treatments were found to be

equally effective.

The efficacy of individual CBT for hypochondriasis has also been demonstrated

in five randomized controlled trials (e.g., Barsky & Ahem, 2004; Visser & Bouman,

2001). Warwick, Clark, Cobb, and Salkovskis (1996) were one of the first groups to

38

For example, Warwick and Marks (1988) evaluated the effectiveness of a CBT for illness

phobia or hypochondriasis with 17 patients with an International Statistical

Classification of Diseases and Related Health Problems 9th Revision (World Health

Organization, 1977) diagnosis. Treatment consisted of seven sessions, on average, during

which exposure and response prevention (i.e., the patient confronts their fears and then

discontinues the usual escape response) was implemented to address avoidance

behaviours (exercise avoidance) and reassurance seeking. Significant improvements

were observed on severity of the patient's main worries (e.g., heart disease), designated

target behaviour(s), vocational and recreational functioning, and on the Fear

Questionnaire (Marks & Mathews, 1979). Treatment gains were maintained for 6 of 13

patients who were followed a median of 5 years.

Bouman and Visser (1998) compared cognitive therapy to behaviour therapy (i.e.,

in vivo exposure plus response prevention) among 17 patients meeting DSM-IV (APA,

1994) criteria for hypochondriasis. Because of the small sample size, patients were used

as their own controls by observing pre- and post-baseline periods of four weeks without

treatment. After the initial interviews, patients were randomly assigned to either of the

two treatment conditions. Patients in both treatment conditions improved on specific

measures of hypochondriasis and depression. The two treatments were found to be

equally effective.

The efficacy of individual CBT for hypochondriasis has also been demonstrated

in five randomized controlled trials (e.g., Barsky & Ahern, 2004; Visser & Bouman,

2001). Warwick, Clark, Cobb, and Salkovskis (1996) were one of the first groups to

38

evaluate the effectiveness of a controlled trial of CBT for hypochondriasis. Thirty-two

patients meeting the DSM-III-R criteria for hypochondriasis were randomly assigned to a

CBT or a wait-list control (WLC) condition. The patients in the active treatment

condition received 16 individual treatment sessions, spread over 4 months. The active

treatment group showed significantly greater improvements than the WLC group on

patient ratings including global problem severity, disease conviction when anxious and

when calm, need for reassurance, time spent worrying about health, health anxiety,

frequency of checking behaviour, depression, and general anxiety. Only frequency of

avoidance behaviours showed no significant differences. The active treatment group also

showed significant improvements compared to the WLC group on therapist ratings of

global problem severity, need for reassurance, health anxiety, and disease conviction.

Finally, the active treatment group showed significant improvements compared to the

WLC group on assessor (blind to treatment allocation) ratings including global problem

severity, disease conviction when anxious and when calm, time spent wanting

reassurance, and strength of need for reassurance. The improvements were maintained at

three months follow-up. The authors concluded that CBT is an acceptable and effective

treatment for hypochondriasis, but they also mentioned a number of limitations of their

study. All treatments were carried out by only one therapist (the first author), so it is

unclear whether other therapists would obtain similar results. One other limitation

included the fact that the follow-up period of three months was relatively short.

In another randomized controlled trial, Clark et al. (1998) compared three

conditions: (1) CBT, (2) behavioural stress management (BSM), and (3) WLC. BSM

39

evaluate the effectiveness of a controlled trial of CBT for hypochondriasis. Thirty-two

patients meeting the DSM-III-R criteria for hypochondriasis were randomly assigned to a

CBT or a wait-list control (WLC) condition. The patients in the active treatment

condition received 16 individual treatment sessions, spread over 4 months. The active

treatment group showed significantly greater improvements than the WLC group on

patient ratings including global problem severity, disease conviction when anxious and

when calm, need for reassurance, time spent worrying about health, health anxiety,

frequency of checking behaviour, depression, and general anxiety. Only frequency of

avoidance behaviours showed no significant differences. The active treatment group also

showed significant improvements compared to the WLC group on therapist ratings of

global problem severity, need for reassurance, health anxiety, and disease conviction.

Finally, the active treatment group showed significant improvements compared to the

WLC group on assessor (blind to treatment allocation) ratings including global problem

severity, disease conviction when anxious and when calm, time spent wanting

reassurance, and strength of need for reassurance. The improvements were maintained at

three months follow-up. The authors concluded that CBT is an acceptable and effective

treatment for hypochondriasis, but they also mentioned a number of limitations of their

study. All treatments were carried out by only one therapist (the first author), so it is

unclear whether other therapists would obtain similar results. One other limitation

included the fact that the follow-up period of three months was relatively short.

In another randomized controlled trial, Clark et al. (1998) compared three

conditions: (1) CBT, (2) behavioural stress management (BSM), and (3) WLC. BSM

39

therapy was a non-specific treatment based on the rationale that some people react to

stress by becoming worried about their health. Thus, such worries are best dealt with by

acquiring a comprehensive set of stress management techniques including relaxation

training, exposure and desensitization, problem solving, assertiveness, time-management

skills, and a stimulus control procedure for postponing worry until a specified "worry

time." Forty-eight patients with hypochondriasis were randomly assigned to one of these

conditions. Each treatment consisted of up to 16 weekly one-hour sessions in the first

four months and up to three booster sessions in the next three months. Both treatment

groups led to significantly improved outcomes as compared to the WLC group. Further,

the CBT group showed improved outcomes as compared to stress-management therapy

on measures of health anxiety at posttreatment, but at 12-month follow-up the advantages

of CBT were no longer evident.

Employing a similar design, Visser and Bouman (2001) conducted a controlled

study to compare the efficacy of in vivo exposure plus response prevention, cognitive

therapy, and WLC. Seventy-eight patients with a DSM-IV-TR diagnosis of

hypochondriasis were randomly assigned to one of these conditions. Each active

treatment consisted of 12 weekly sessions, followed by a four-week interval without

treatment. At both post-treatment and seven-month follow-up, the two forms of

treatment were deemed equally effective and produced significantly improved outcomes

(i.e., reduced health anxiety, illness behaviour, somatosensory amplification, symptoms

of somatization, ratings of idiosyncratic hypochondriacal situations and cognitions,

symptoms of depression, obsessive-compulsive complaints, and general mental

40

therapy was a non-specific treatment based on the rationale that some people react to

stress by becoming worried about their health. Thus, such worries are best dealt with by

acquiring a comprehensive set of stress management techniques including relaxation

training, exposure and desensitization, problem solving, assertiveness, time-management

skills, and a stimulus control procedure for postponing worry until a specified "worry

time." Forty-eight patients with hypochondriasis were randomly assigned to one of these

conditions. Each treatment consisted of up to 16 weekly one-hour sessions in the first

four months and up to three booster sessions in the next three months. Both treatment

groups led to significantly improved outcomes as compared to the WLC group. Further,

the CBT group showed improved outcomes as compared to stress-management therapy

on measures of health anxiety at posttreatment, but at 12-month follow-up the advantages

of CBT were no longer evident.

Employing a similar design, Visser and Bouman (2001) conducted a controlled

study to compare the efficacy of in vivo exposure plus response prevention, cognitive

therapy, and WLC. Seventy-eight patients with a DSM-IV-TR diagnosis of

hypochondriasis were randomly assigned to one of these conditions. Each active

treatment consisted of 12 weekly sessions, followed by a four-week interval without

treatment. At both post-treatment and seven-month follow-up, the two forms of

treatment were deemed equally effective and produced significantly improved outcomes

(i.e., reduced health anxiety, illness behaviour, somatosensory amplification, symptoms

of somatization, ratings of idiosyncratic hypochondriacal situations and cognitions,

symptoms of depression, obsessive-compulsive complaints, and general mental

40

functioning) compared to the WLC group. However, the high drop-out rate in this study

(28.2%) limits the generalizability of the findings.

More recently, using a randomized, usual care control group design, Barsky and

Ahern (2004) found support for the efficacy of a six session CB intervention. One

hundred and two individuals who exceeded the cut-off score on a self-report

hypochondriasis questionnaire were assigned to CBT and 85 were assigned to medical

care as usual. CBT was administered individually in six sessions at weekly intervals.

Factors that are thought to be related to patient amplification of somatic symptoms and

misattribution of these factors to serious disease were covered, including attention and

bodily hypervigilance, beliefs about symptom etiology, circumstances and context, illness

and sick role behaviours, and mood. Each session consisted of educational information

about the symptom amplifiers, an illustrative exercise, and a discussion to personalize the

material presented. The CBT group showed significantly improved outcomes (i.e.,

reduced hypochondriacal symptoms, attitudes and beliefs, health-related anxiety,

somatosensory amplification, and intermediate activities of daily living) as compared to

the WLC group at both 6- and 12-month follow-up. At 12-month follow-up, CBT

patients had significantly lower levels of hypochondriacal symptoms, beliefs and

attitudes, and health-related anxiety. Significant improvements in social functioning

were not identified until the 12-month follow-up. They also had significantly less

impairment of intermediate activities of daily living. Hypochondriacal somatic

symptoms were not improved significantly by treatment, but this was not one of the aims

of treatment, since the focus was on helping the patients cope with these symptoms.

41

functioning) compared to the WLC group. However, the high drop-out rate in this study

(28.2%o) limits the generalizability of the findings.

More recently, using a randomized, usual care control group design, Barsky and

Ahem (2004) found support for the efficacy of a six session CB intervention. One

hundred and two individuals who exceeded the cut-off score on a self-report

hypochondriasis questionnaire were assigned to CBT and 85 were assigned to medical

care as usual. CBT was administered individually in six sessions at weekly intervals.

Factors that are thought to be related to patient amplification of somatic symptoms and

misattribution of these factors to serious disease were covered, including attention and

bodily hypervigilance, beliefs about symptom etiology, circumstances and context, illness

and sick role behaviours, and mood. Each session consisted of educational information

about the symptom amplifiers, an illustrative exercise, and a discussion to personalize the

material presented. The CBT group showed significantly improved outcomes (i.e.,

reduced hypochondriacal symptoms, attitudes and beliefs, health-related anxiety,

somatosensory amplification, and intermediate activities of daily living) as compared to

the WLC group at both 6- and 12-month follow-up. At 12-month follow-up, CBT

patients had significantly lower levels of hypochondriacal symptoms, beliefs and

attitudes, and health-related anxiety. Significant improvements in social functioning

were not identified until the 12-month follow-up. They also had significantly less

impairment of intermediate activities of daily living. Hypochondriacal somatic

symptoms were not improved significantly by treatment, but this was not one of the aims

of treatment, since the focus was on helping the patients cope with these symptoms.

41

Taylor, Asmundson, and Coons (2005) conducted a meta-analysis of 25 trials

examining various treatments for health anxiety, in order to gain a greater understanding

of the relative efficacy of these interventions. Psychosocial treatments that were

reviewed included psychoeducation, explanatory therapy (an approach based primarily on

providing a large amount of reassurance, anxiolytic medication when the patient becomes

anxious, and psychoeduction; Kellner, 1979; Taylor & Asmundson, 2004), cognitive

therapy, exposure and response prevention, CBT, and behavioural stress management.

Four different types of drug treatments were reviewed and included paroxetine,

fluoxetine, fluvoxamine, and nefazodone. Participants in the studies that were included

either had full or abridged hypochondriasis (i.e., differs from full-blown hypochondriasis

in that one or more of the diagnostic features of hypochondriasis are not present; Taylor

& Asmundson, 2004). They were typically aged in their 30s or 40s, and approximately

two-thirds were female. The duration of health anxiety, when reported, was typically

several years. Patients in drug trials were on their medications at the time of the post-

treatment assessment. For studies of full-blown hypochondriasis, the post-treatment

effect sizes for measures of hypochondriasis suggested that CBT and fluoxetine yielded

the largest effects for treatment completers. The mean estimated effect size for CBT was

2.05 and the mean estimated effect size for fluoxetine was 1.92.

Taylor et al. (2005) suggested the following from the meta-analysis results. First,

for measures of hypochondriasis, all of the psychosocial and drug treatments had larger

effect sizes than WLCs. This indicates that the clinician's skills are useful in the

treatment of health anxiety. When treatment acceptability, and strength, breadth, and

42

Taylor, Asmundson, and Coons (2005) conducted a meta-analysis of 25 trials

examining various treatments for health anxiety, in order to gain a greater understanding

of the relative efficacy of these interventions. Psychosocial treatments that were

reviewed included psychoeducation, explanatory therapy (an approach based primarily on

providing a large amount of reassurance, anxiolytic medication when the patient becomes

anxious, and psychoeduction; Kellner, 1979; Taylor & Asmundson, 2004), cognitive

therapy, exposure and response prevention, CBT, and behavioural stress management.

Four different types of drug treatments were reviewed and included paroxetine,

fluoxetine, fluvoxamine, and nefazodone. Participants in the studies that were included

either had full or abridged hypochondriasis (i.e., differs from full-blown hypochondriasis

in that one or more of the diagnostic features of hypochondriasis are not present; Taylor

& Asmundson, 2004). They were typically aged in their 30s or 40s, and approximately

two-thirds were female. The duration of health anxiety, when reported, was typically

several years. Patients in drug trials were on their medications at the time of the post-

treatment assessment. For studies of full-blown hypochondriasis, the post-treatment

effect sizes for measures of hypochondriasis suggested that CBT and fluoxetine yielded

the largest effects for treatment completers. The mean estimated effect size for CBT was

2.05 and the mean estimated effect size for fluoxetine was 1.92.

Taylor et al. (2005) suggested the following from the meta-analysis results. First,

for measures of hypochondriasis, all of the psychosocial and drug treatments had larger

effect sizes than WLCs. This indicates that the clinician's skills are useful in the

treatment of health anxiety. When treatment acceptability, and strength, breadth, and

42

durability of effects were taken into consideration, Taylor et al. (2005) suggested that

CBT is the treatment of choice for full hypochondriasis. However, for mixed full and

abridged hypochondriasis, they suggest that psychoeducation might be adequate for many

patients with mild health anxiety, especially if the person is not depressed. If depression

plays a factor in cases of abridged hypochondriasis, CBT for health anxiety may be more

beneficial because it appeared to be superior to psychoeducation in reducing depression.

The results, however, need to be interpreted with caution as the sample sizes tended to be

small in most of the studies included.

Since the time of this review, Seivewright et al. (2008) conducted a randomised

controlled trial to compare the efficacy of CBT versus WLC in the treatment of health

anxiety. Twenty-three patients were randomised to the CBT group and 26 patients were

randomised to the WLC control group. The active treatment consisted of an average of

4.3 sessions (range 0-13) of 45-60 minutes over a six-month period. Participants in the

active treatment received CBT supplemented by a booklet (bibliotherapy). At both post-

treatment and six-month follow-up, CBT produced significantly improved outcomes on

health anxiety, generalized anxiety, and depression compared to the WLC control group.

In another recent randomized controlled trial, Sorensen, Birket-Smith, Wattar, and

Salkovskis (in press) compared three conditions: (1) CBT, (2) short-term psychodynamic

psychotherapy (STPP), and (3) WLC in the treatment of hypochondriasis. Eighty

patients with hypochondriasis were randomly assigned to one of these conditions. The

CBT program consisted of eight individual sessions and eight group sessions. The STPP

program consisted of 16 weekly sessions. Patients in the WLC group were asked to keep

43

durability of effects were taken into consideration, Taylor et al. (2005) suggested that

CBT is the treatment of choice for full hypochondriasis. However, for mixed full and

abridged hypochondriasis, they suggest that psychoeducation might be adequate for many

patients with mild health anxiety, especially if the person is not depressed. If depression

plays a factor in cases of abridged hypochondriasis, CBT for health anxiety may be more

beneficial because it appeared to be superior to psychoeducation in reducing depression.

The results, however, need to be interpreted with caution as the sample sizes tended to be

small in most of the studies included.

Since the time of this review, Seivewright et al. (2008) conducted a randomised

controlled trial to compare the efficacy of CBT versus WLC in the treatment of health

anxiety. Twenty-three patients were randomised to the CBT group and 26 patients were

randomised to the WLC control group. The active treatment consisted of an average of

4.3 sessions (range 0-13) of 45-60 minutes over a six-month period. Participants in the

active treatment received CBT supplemented by a booklet (bibliotherapy). At both post-

treatment and six-month follow-up, CBT produced significantly improved outcomes on

health anxiety, generalized anxiety, and depression compared to the WLC control group.

In another recent randomized controlled trial, Sorensen, Birket-Smith, Wattar, and

Salkovskis (in press) compared three conditions: (1) CBT, (2) short-term psychodynamic

psychotherapy (STPP), and (3) WLC in the treatment of hypochondriasis. Eighty

patients with hypochondriasis were randomly assigned to one of these conditions. The

CBT program consisted of eight individual sessions and eight group sessions. The STPP

program consisted of 16 weekly sessions. Patients in the WLC group were asked to keep

43

in touch with their family physician, and they were instructed not to begin any other

treatment during the study period. The patients receiving CBT had significant

improvements compared to the WLC group on measures of health anxiety, generalized

anxiety, and depression and compared to the STPP group on measures of health anxiety

and depression. The STPP group did not show significant improvements relative to the

WLC group on any measures. At follow-up, CBT did significantly better than STPP on

all measures with the exception of one generalized anxiety measure. The above

described results suggest that CBT is effective in the treatment of health anxiety.

1.8.2 Enhancing CBT for Use with Older Adults

Empirical evidence for the effectiveness of CB interventions with seniors has

grown over the past 30 years (Satre, Knight, & David, 2006). These studies have used

treatment manuals specifically adapted for older adults, taking into account the changes

that occur through the aging process (Mohlman et al., 2003; Stanley, Diefenbach, &

Hopko, 2004). A number of adaptations for treatment of older adults have been

suggested in the gerontological literature. For example, some older adults may

experience cognitive decline, which can be problematic during psychotherapy (Snyder &

Stanley, 2001). In order to facilitate patient understanding, abbreviated sessions focused

on concrete tasks have been suggested as a way to improve outcome. Treatment may

also take a greater number of sessions compared with younger adults (Snyder & Stanley,

2001). To facilitate comprehension, terms should be simplified, removing possible

communication barriers between therapist and the older patient (Snyder & Stanley, 2001).

Clinicians should consider any modifications of terms necessary to fit the patient's

44

in touch with their family physician, and they were instructed not to begin any other

treatment during the study period. The patients receiving CBT had significant

improvements compared to the WLC group on measures of health anxiety, generalized

anxiety, and depression and compared to the STPP group on measures of health anxiety

and depression. The STPP group did not show significant improvements relative to the

WLC group on any measures. At follow-up, CBT did significantly better than STPP on

all measures with the exception of one generalized anxiety measure. The above

described results suggest that CBT is effective in the treatment of health anxiety.

1.8.2 Enhancing CBT for Use with Older Adults

Empirical evidence for the effectiveness of CB interventions with seniors has

grown over the past 30 years (Satre, Knight, & David, 2006). These studies have used

treatment manuals specifically adapted for older adults, taking into account the changes

that occur through the aging process (Mohlman et al., 2003; Stanley, Diefenbach, &

Hopko, 2004). A number of adaptations for treatment of older adults have been

suggested in the gerontological literature. For example, some older adults may

experience cognitive decline, which can be problematic during psychotherapy (Snyder &

Stanley, 2001). In order to facilitate patient understanding, abbreviated sessions focused

on concrete tasks have been suggested as a way to improve outcome. Treatment may

also take a greater number of sessions compared with younger adults (Snyder & Stanley,

2001). To facilitate comprehension, terms should be simplified, removing possible

communication barriers between therapist and the older patient (Snyder & Stanley, 2001).

Clinicians should consider any modifications of terms necessary to fit the patient's

44

educational background, cognitive skills, and preferences (e.g., nervous or concerned

instead of worried; classes rather than treatment sessions; Stanley et al., 2004). Written

materials summarizing the information covered during treatment sessions might also be

useful as a reference for between-session reviews (Snyder & Stanley, 2001). Further, the

addition of learning and memory aids designed to increase homework compliance,

strengthen memory for techniques, and facilitate the use of these techniques have been

found to be useful in psychotherapy with older adults (Mohlman et al., 2003). For

instance, modifications of homework assignments may be necessary for some patients

(e.g., use of audiotapes, enlarged homework forms, simplified checklists). In other cases,

treatment may need to occur at a generally slower pace than is recommended, and with

less intensive homework assignments overall (e.g., practicing only one skill each day). In

addition, some patients may find the cognitive restructuring component difficult to

comprehend. In these cases, the overall amount of time spent on cognitive restructuring

can be decreased (Stanley et al., 2004).

A number of studies have adapted CBT specifically for seniors and have used

modifications, such as making examples more relevant to older people (e.g., Wetherall,

Gatz, & Craske, 2003). Mohlman and colleagues (2003) compared the efficacy of an

enhanced individual-format CBT administered in a mental health clinic for treatment of

late-life GAD to a standard CBT format. Study 1 compared the standard version of CBT

with a WLC group. Study 2 compared an enhanced version (ECBT) that included

learning and memory aids designed to make the therapy more effective with older adults

to a WLC. These enhancements were derived from articles and workshop materials

45

educational background, cognitive skills, and preferences (e.g., nervous or concerned

instead of worried; classes rather than treatment sessions; Stanley et al., 2004). Written

materials summarizing the information covered during treatment sessions might also be

useful as a reference for between-session reviews (Snyder & Stanley, 2001). Further, the

addition of learning and memory aids designed to increase homework compliance,

strengthen memory for techniques, and facilitate the use of these techniques have been

found to be useful in psychotherapy with older adults (Mohlman et al., 2003). For

instance, modifications of homework assignments may be necessary for some patients

(e.g., use of audiotapes, enlarged homework forms, simplified checklists). In other cases,

treatment may need to occur at a generally slower pace than is recommended, and with

less intensive homework assignments overall (e.g., practicing only one skill each day). In

addition, some patients may find the cognitive restructuring component difficult to

comprehend. In these cases, the overall amount of time spent on cognitive restructuring

can be decreased (Stanley et al, 2004).

A number of studies have adapted CBT specifically for seniors and have used

modifications, such as making examples more relevant to older people (e.g., Wetherall,

Gatz, & Craske, 2003). Mohlman and colleagues (2003) compared the efficacy of an

enhanced individual-format CBT administered in a mental health clinic for treatment of

late-life GAD to a standard CBT format. Study 1 compared the standard version of CBT

with a WLC group. Study 2 compared an enhanced version (ECBT) that included

learning and memory aids designed to make the therapy more effective with older adults

to a WLC. These enhancements were derived from articles and workshop materials

45

focused on tailoring CBT to older adults (Knight & Satre, 1999) or were devised by

Mohlman himself. Immediately following completion of the intervention, Study 1 CBT

participants showed significant improvement on GAD severity ratings. Study 2 EBCT

participants showed significant improvement on two self-report measures, rates of post-

treatment GAD, and GAD severity ratings. ECBT resulted in improvement on more

measures and yielded larger effect sizes than standard CBT, when each was compared

against a WLC group (Mohlman et al., 2003). This data remain preliminary as no further

follow-up data have been published.

1.8.3 Reasons Why CBT May Be Effective with Older Adults

Morris and Morris (1991) state that there are a number of reasons why CB

interventions can be particularly effective with older people. First, CBT is focused on the

`here and now.' The individual's current needs are identified and interventions are

developed to target specific stressors. Second, CBT is skills enhancing and practical.

The organized nature of therapy can help to keep the person oriented to tasks within and

across sessions. Homework is used to keep the individual focused on managing

problems. Third, CBT encourages self-monitoring. The individual is taught to recognize

mood fluctuations and emotional vulnerabilities and to develop strategies that enhance

coping ability. Fourth, it is educative. The connection between thoughts, mood, and

behaviour is explained, and the model explains the impact of negative cycles of

problematic emotion states (e.g., depression, anxiety) upon the person's activity level and

vice versa. Fifth, CBT is goal oriented. Interventions are developed to challenge

stereotyped beliefs (i.e., 'You can't teach an old dog new tricks').

46

focused on tailoring CBT to older adults (Knight & Satre, 1999) or were devised by

Mohlman himself. Immediately following completion of the intervention, Study 1 CBT

participants showed significant improvement on GAD severity ratings. Study 2 EBCT

participants showed significant improvement on two self-report measures, rates of post-

treatment GAD, and GAD severity ratings. ECBT resulted in improvement on more

measures and yielded larger effect sizes than standard CBT, when each was compared

against a WLC group (Mohlman et al., 2003). This data remain preliminary as no further

follow-up data have been published.

1.8.3 Reasons Why CBT May Be Effective with Older Adults

Morris and Morris (1991) state that there are a number of reasons why CB

interventions can be particularly effective with older people. First, CBT is focused on the

'here and now.' The individual's current needs are identified and interventions are

developed to target specific stressors. Second, CBT is skills enhancing and practical.

The organized nature of therapy can help to keep the person oriented to tasks within and

across sessions. Homework is used to keep the individual focused on managing

problems. Third, CBT encourages self-monitoring. The individual is taught to recognize

mood fluctuations and emotional vulnerabilities and to develop strategies that enhance

coping ability. Fourth, it is educative. The connection between thoughts, mood, and

behaviour is explained, and the model explains the impact of negative cycles of

problematic emotion states (e.g., depression, anxiety) upon the person's activity level and

vice versa. Fifth, CBT is goal oriented. Interventions are developed to challenge

stereotyped beliefs (i.e., 'You can't teach an old dog new tricks').

46

As described above, individual CBT for health anxiety has proven to be effective

in a variety of samples. However, this treatment awaits testing in samples of older adults.

Nonetheless, it would appear that with some modifications CBT could be applied to

samples of seniors. Given the limited resources of the health care system it is also

important to investigate less costly methods of providing CBT for health anxiety. In this

regard, examining the effectiveness of providing patients with a brief intervention for

health anxiety is a worthy endeavour.

1.8.4 Fostering the Therapeutic Alliance

Although some patients receiving treatment for health anxiety will be

apprehensive about psychological interventions, this may be especially true for older

adults who are often unsure about seeking treatment for psychological difficulties

(Lasocki, 1986). Small (1997) attributed this reluctance to the fact that some older adults

associate psychological problems with 'being crazy' or as a sign that they are weak. This

is often reinforced by physicians who tell the older adult that their problems are 'all in

their head' because they cannot find a biomedical cause for reported symptoms (Snyder

& Stanley, 2001). As a result, the relationship between the client and therapist is

especially important when treating older adults with health anxiety. Their potential lack

of trust for mental health professionals and possible disappointment at being referred by

their physicians can be improved through the development of a strong relationship

(Snyder & Stanley, 2001). Thus, treatment programs specifically tailored to the older

adult population may help to foster the relationship between the client and therapist,

47

As described above, individual CBT for health anxiety has proven to be effective

in a variety of samples. However, this treatment awaits testing in samples of older adults.

Nonetheless, it would appear that with some modifications CBT could be applied to

samples of seniors. Given the limited resources of the health care system it is also

important to investigate less costly methods of providing CBT for health anxiety. In this

regard, examining the effectiveness of providing patients with a brief intervention for

health anxiety is a worthy endeavour.

1.8.4 Fostering the Therapeutic Alliance

Although some patients receiving treatment for health anxiety will be

apprehensive about psychological interventions, this may be especially true for older

adults who are often unsure about seeking treatment for psychological difficulties

(Lasocki, 1986). Small (1997) attributed this reluctance to the fact that some older adults

associate psychological problems with 'being crazy' or as a sign that they are weak. This

is often reinforced by physicians who tell the older adult that their problems are 'all in

their head' because they cannot find a biomedical cause for reported symptoms (Snyder

& Stanley, 2001). As a result, the relationship between the client and therapist is

especially important when treating older adults with health anxiety. Their potential lack

of trust for mental health professionals and possible disappointment at being referred by

their physicians can be improved through the development of a strong relationship

(Snyder & Stanley, 2001). Thus, treatment programs specifically tailored to the older

adult population may help to foster the relationship between the client and therapist,

47

commonly known as the therapeutic alliance, resulting in greater improvement in mental

health.

The therapeutic alliance pertains to the collaborative nature of the relationship, the

affective bond between therapist and patient, the patient's trust in the therapist, and

agreement on goals by both the therapist and patient (Bordin, 1979; Horvath & Symonds,

1991). Several studies have shown that the therapeutic alliance is related to outcome

(e.g., Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000; Krupnick et al.,

1996; Martin, Garske, & Davis, 2000). Moreover, Horvath and Symonds (1991) showed

that, in general, the better the therapeutic alliance, the better the outcome. Marmar,

Gaston, Gallagher, and Thompson (1989) reported that for older patients with depression

treated in behavioural, cognitive, or brief dynamic psychotherapy, the alliance assessed

early in treatment was moderately associated with outcome, with the strongest results in

cognitive therapy. In the same sample of participants, Gaston, Marmar, Gallagher, and

Thompson (1991) examined the relationship between the therapeutic alliance and

outcome over and above initial symptomatology and in-treatment symptomatic change.

To measure therapy progress, participants completed the California Psychotherapy

Alliance Scales (CALPAS; Marmar, Weiss, & Gaston, 1989), after the 5th, 10th, and 15th

sessions. For the whole sample, no substantial association was found between alliance

and outcome. However, within treatment conditions, the alliance uniquely contributed to

outcome with increasing variance accounted for as therapy progressed, and especially in

behavioural and cognitive therapy; from 19% and 32% at the 5th session, to 36% and

57% at the 15th session.

48

commonly known as the therapeutic alliance, resulting in greater improvement in mental

health.

The therapeutic alliance pertains to the collaborative nature of the relationship, the

affective bond between therapist and patient, the patient's trust in the therapist, and

agreement on goals by both the therapist and patient (Bordin, 1979; Horvath & Symonds,

1991). Several studies have shown that the therapeutic alliance is related to outcome

(e.g., Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000; Krupnick et al.,

1996; Martin, Garske, & Davis, 2000). Moreover, Horvath and Symonds (1991) showed

that, in general, the better the therapeutic alliance, the better the outcome. Marmar,

Gaston, Gallagher, and Thompson (1989) reported that for older patients with depression

treated in behavioural, cognitive, or brief dynamic psychotherapy, the alliance assessed

early in treatment was moderately associated with outcome, with the strongest results in

cognitive therapy. In the same sample of participants, Gaston, Marmar, Gallagher, and

Thompson (1991) examined the relationship between the therapeutic alliance and

outcome over and above initial symptomatology and in-treatment symptomatic change.

To measure therapy progress, participants completed the California Psychotherapy

Alliance Scales (CALPAS; Marmar, Weiss, & Gaston, 1989), after the 5th, 10th, and 15th

sessions. For the whole sample, no substantial association was found between alliance

and outcome. However, within treatment conditions, the alliance uniquely contributed to

outcome with increasing variance accounted for as therapy progressed, and especially in

behavioural and cognitive therapy; from 19% and 32% at the 5th session, to 36% and

57% at the 15th session.

48

Recently, Zuroff and Blatt (2006) examined the impact of the patient's perception

of the quality of the therapeutic relationship and involvement of the therapeutic alliance

to treatment outcome during brief treatments of depression among 191 outpatients with

nonbipolar, nonpsychotic major depressive disorder. Patients were randomly assigned to

four treatment conditions including CBT, interpersonal therapy (IPT), and two separate

conditions for clinical management with medication. The authors demonstrated that a

positive therapeutic relationship perceived by the client early in treatment predicted more

rapid reduction in emotional difficulties following the initial relationship assessment.

This effect occurred equally across all four treatment conditions. A positive early

therapeutic relationship also predicted better emotional adjustment throughout the 18-

month follow-up as well as development of greater enhanced coping. Controlling a wide

range of patient characteristics did not eliminate the effects of the therapeutic relationship

on rate of improvement during treatment and on enhanced coping. Thus, Zuroff and Blatt

(2006) suggest that, independent of type of treatment and early clinical improvement, the

therapeutic relationship contributes directly to positive therapeutic outcome.

Unfortunately, the therapeutic alliance has not been widely assessed or discussed with

respect to older adults.

Hyer and Kramer (2004) have some suggestions for how CBT with older adults

can be altered to foster the therapeutic alliance. First, enhancing common therapy factors

and building a strong alliance are proactive initiatives that require a planned, focused

effort to conduct psychotherapy within the client's frame of reference. Second, with older

people, considerable effort should be directed toward increasing the client's involvement

49

Recently, Zuroff and Blatt (2006) examined the impact of the patient's perception

of the quality of the therapeutic relationship and involvement of the therapeutic alliance

to treatment outcome during brief treatments of depression among 191 outpatients with

nonbipolar, nonpsychotic major depressive disorder. Patients were randomly assigned to

four treatment conditions including CBT, interpersonal therapy (IPT), and two separate

conditions for clinical management with medication. The authors demonstrated that a

positive therapeutic relationship perceived by the client early in treatment predicted more

rapid reduction in emotional difficulties following the initial relationship assessment.

This effect occurred equally across all four treatment conditions. A positive early

therapeutic relationship also predicted better emotional adjustment throughout the 18-

month follow-up as well as development of greater enhanced coping. Controlling a wide

range of patient characteristics did not eliminate the effects of the therapeutic relationship

on rate of improvement during treatment and on enhanced coping. Thus, Zuroff and Blatt

(2006) suggest that, independent of type of treatment and early clinical improvement, the

therapeutic relationship contributes directly to positive therapeutic outcome.

Unfortunately, the therapeutic alliance has not been widely assessed or discussed with

respect to older adults.

Hyer and Kramer (2004) have some suggestions for how CBT with older adults

can be altered to foster the therapeutic alliance. First, enhancing common therapy factors

and building a strong alliance are proactive initiatives that require a planned, focused

effort to conduct psychotherapy within the client's frame of reference. Second, with older

people, considerable effort should be directed toward increasing the client's involvement

49

in therapy. This, combined with presentation of the principles underlying the symptoms

and therapeutic process, is the main goal of socialization. Blazer (1998) noted that the

best path to communication with the older client is to conduct an effective interview

during which the therapist validates and gives both respect and dignity to the client. This

allows the client time to express concerns and feel as though they are being listened to.

The principles of therapy are repeated across all sessions to foster retention (Gallagher-

Thompson & Thompson, 1995). Normalizing symptoms and providing perspective on

the role of the client are parts of this process. Third, the emphasis within therapy is on

coping and a positive view of problems, as aging can be a time in which change and

decline in functioning often occurs, resulting in problems, disease, and loss. The focus of

therapy is doing the best with what one has.

1.8.5 Motivation in Psychotherapy

Patient motivation for treatment has been considered to be vital to psychotherapy

progress and outcome (Keijsers, Schaap, Hoogduin, Hoogsteyns, & de Kemp, 1999). In

psychotherapy, the client not only receives treatment but must actively participate in it.

Thus, motivation to participate is a vital factor in the outcome of treatment (Krause,

1966). Treatment motivation is often seen as important because there is an assumed

relationship with treatment-related behaviour such as adherence, compliance, or treatment

engagement (Drieschner, Lammers, & van der Staak, 2004). For example, Ryan, Plant,

and O'Malley (1995) noted that lack of motivation is one of the most frequently

mentioned reasons for client dropout, failure to comply, relapse, and other negative

treatment outcomes.

50

in therapy. This, combined with presentation of the principles underlying the symptoms

and therapeutic process, is the main goal of socialization. Blazer (1998) noted that the

best path to communication with the older client is to conduct an effective interview

during which the therapist validates and gives both respect and dignity to the client. This

allows the client time to express concerns and feel as though they are being listened to.

The principles of therapy are repeated across all sessions to foster retention (Gallagher-

Thompson & Thompson, 1995). Normalizing symptoms and providing perspective on

the role of the client are parts of this process. Third, the emphasis within therapy is on

coping and a positive view of problems, as aging can be a time in which change and

decline in functioning often occurs, resulting in problems, disease, and loss. The focus of

therapy is doing the best with what one has.

1.8.5 Motivation in Psychotherapy

Patient motivation for treatment has been considered to be vital to psychotherapy

progress and outcome (Keijsers, Schaap, Hoogduin, Hoogsteyns, & de Kemp, 1999). In

psychotherapy, the client not only receives treatment but must actively participate in it.

Thus, motivation to participate is a vital factor in the outcome of treatment (Krause,

1966). Treatment motivation is often seen as important because there is an assumed

relationship with treatment-related behaviour such as adherence, compliance, or treatment

engagement (Drieschner, Lammers, & van der Staak, 2004). For example, Ryan, Plant,

and O'Malley (1995) noted that lack of motivation is one of the most frequently

mentioned reasons for client dropout, failure to comply, relapse, and other negative

treatment outcomes.

50

Motivation for psychotherapy among individuals with health anxiety is an

important factor. Individuals with health anxiety seek therapy for a number of different

reasons (Taylor & Asmundson, 2004). Some individuals recognize that they have a

problem with anxiety and it needs to be treated. Others are persuaded or even coerced

into seeking therapy by their family or physicians. These individuals may be reluctant to

engage in therapy and may, in fact, have the goal of proving that their problems are not

"all in their head" and that they are not mentally disordered (Warwick, 1995). These

individuals may not fully participate in therapy because they believe that medical

intervention would be of greater help than psychological intervention. Thus, strategies

that enhance motivation are often a vital prerequisite (Taylor & Asmundson, 2004).

In CBT, considerable attention has been paid to ways of motivating patients to

comply with treatment techniques and homework assignments (e.g., Curtis, 1984;

Horvath, 1993). Several researchers have conceptualized patient motivation as a state of

readiness for change prior to the beginning of treatment interventions (Keijsers et al.,

1999). Conceptualized in this way, patient motivation includes the acknowledgement of

problems, level of distress, commitment for change, or credibility or acceptance of

psychological treatment (e.g., Miller & Rollnick, 1992; Nelson & Borkovec, 1989).

Other researchers have focused on criteria for patients' actual participation, cooperation,

or compliance during the course of treatment (Keijsers et al., 1999). Because complaint

reduction has been attributed in large part to the patients' accomplishment and

implementation of new and more effective coping behaviour, this suggests that treatment

51

Motivation for psychotherapy among individuals with health anxiety is an

important factor. Individuals with health anxiety seek therapy for a number of different

reasons (Taylor & Asmundson, 2004). Some individuals recognize that they have a

problem with anxiety and it needs to be treated. Others are persuaded or even coerced

into seeking therapy by their family or physicians. These individuals may be reluctant to

engage in therapy and may, in fact, have the goal of proving that their problems are not

"all in their head" and that they are not mentally disordered (Warwick, 1995). These

individuals may not fully participate in therapy because they believe that medical

intervention would be of greater help than psychological intervention. Thus, strategies

that enhance motivation are often a vital prerequisite (Taylor & Asmundson, 2004).

In CBT, considerable attention has been paid to ways of motivating patients to

comply with treatment techniques and homework assignments (e.g., Curtis, 1984;

Horvath, 1993). Several researchers have conceptualized patient motivation as a state of

readiness for change prior to the beginning of treatment interventions (Keijsers et al.,

1999). Conceptualized in this way, patient motivation includes the acknowledgement of

problems, level of distress, commitment for change, or credibility or acceptance of

psychological treatment (e.g., Miller & Rollnick, 1992; Nelson & Borkovec, 1989).

Other researchers have focused on criteria for patients' actual participation, cooperation,

or compliance during the course of treatment (Keijsers et al., 1999). Because complaint

reduction has been attributed in large part to the patients' accomplishment and

implementation of new and more effective coping behaviour, this suggests that treatment

51

compliance is a more direct predictor of CBT outcome than initial patient motivation

(Keijsers et al., 1999).

In the majority of studies investigating patient initial motivation in CBT,

motivation was found to be significantly related to outcome (Haan et al., 1997; Hoogduin

& Duivenvoorden, 1988; Nelson & Borkovec, 1989; Schefft & Kanfer, 1987; Simpson &

Joe, 1993). High initial motivation appears to be associated with better treatment

outcome and lower dropout rate. However, motivation in CBT among older adults has

not been examined. Thus, one purpose of this study is to assess whether motivation for

therapy improved over six sessions of therapy.

To help enhance the therapeutic alliance and foster motivation for psychotherapy

in this sample of older adults, an enhanced cognitive behavioural therapy (ECBT) for

health anxiety will be tested. Memory and learning aids as well as a short video (one for

each of the six sessions) with an older adult actor demonstrating and giving a testimonial

of how the program improved their symptoms will be shown to participants. The goal of

using these videos will also be to enhance the therapeutic alliance and patient motivation,

and ultimately improve health anxiety and its related symptoms.

1.9 Research Problem and Purpose

Two separate studies were conducted. The purpose of Study 1 was to examine the

efficacy of a standard and an enhanced six-session CB intervention for health anxiety for

older adults in comparison to a WLC group. To date, no research has examined the

effectiveness of CBT for health anxiety among older adults. Results from previous

research assessing the efficacy of ECBT in comparison with standard cognitive

52

compliance is a more direct predictor of CBT outcome than initial patient motivation

(Keijsers etal., 1999).

In the majority of studies investigating patient initial motivation in CBT,

motivation was found to be significantly related to outcome (Haan et al., 1997; Hoogduin

& Duivenvoorden, 1988; Nelson & Borkovec, 1989; Schefft & Kanfer, 1987; Simpson &

Joe, 1993). High initial motivation appears to be associated with better treatment

outcome and lower dropout rate. However, motivation in CBT among older adults has

not been examined. Thus, one purpose of this study is to assess whether motivation for

therapy improved over six sessions of therapy.

To help enhance the therapeutic alliance and foster motivation for psychotherapy

in this sample of older adults, an enhanced cognitive behavioural therapy (ECBT) for

health anxiety will be tested. Memory and learning aids as well as a short video (one for

each of the six sessions) with an older adult actor demonstrating and giving a testimonial

of how the program improved their symptoms will be shown to participants. The goal of

using these videos will also be to enhance the therapeutic alliance and patient motivation,

and ultimately improve health anxiety and its related symptoms.

1.9 Research Problem and Purpose

Two separate studies were conducted. The purpose of Study 1 was to examine the

efficacy of a standard and an enhanced six-session CB intervention for health anxiety for

older adults in comparison to a WLC group. To date, no research has examined the

effectiveness of CBT for health anxiety among older adults. Results from previous

research assessing the efficacy of ECBT in comparison with standard cognitive

52

behavioural therapy (SCBT) for GAD among older adults suggested that it may be

important to enhance CBT for it to be effective with older adults (Mohlman et al., 2003).

Therefore, comparison of ECBT to a SCBT and a WLC condition was expected to

demonstrate that learning and memory aids and educational videos would lead to greater

reduction in symptoms of health anxiety among older adults (see Figure 2, pg. 37). A

further purpose of Study 1 was to examine whether the ECBT program promoted a higher

level of therapeutic alliance and motivation for psychotherapy as compared to the SCBT

program. This research was thought to be valuable because establishing and fostering a

strong therapeutic alliance and motivation for psychotherapy has been related to outcome

in psychotherapy (Snyder & Stanley, 2001), but could be challenging to establish with

older adults. A further objective of Study 1 was to gain a greater understanding of the

nature of health anxiety among older adults. This was examined through qualitative

analysis of the participants' responses to semi-structured interview questions regarding

development and maintenance of health anxiety. Study 1 was also used to collect

qualitative information from older participants on their experiences with CBT. A

secondary study was conducted to clarify the relationship between age and health anxiety.

The purpose of Study 2 was to examine differences between an older adult group and a

younger adult group control group with similar levels of health anxiety as measured by a

common measure of health anxiety. The goal was to examine whether the nature of the

two groups' concerns on various dimensions of health anxiety was comparable or

whether the pattern of responses differed. Specifically, the older adult and younger adult

53

behavioural therapy (SCBT) for GAD among older adults suggested that it may be

important to enhance CBT for it to be effective with older adults (Mohlman et al., 2003).

Therefore, comparison of ECBT to a SCBT and a WLC condition was expected to

demonstrate that learning and memory aids and educational videos would lead to greater

reduction in symptoms of health anxiety among older adults (see Figure 2, pg. 37). A

further purpose of Study 1 was to examine whether the ECBT program promoted a higher

level of therapeutic alliance and motivation for psychotherapy as compared to the SCBT

program. This research was thought to be valuable because establishing and fostering a

strong therapeutic alliance and motivation for psychotherapy has been related to outcome

in psychotherapy (Snyder & Stanley, 2001), but could be challenging to establish with

older adults. A further objective of Study 1 was to gain a greater understanding of the

nature of health anxiety among older adults. This was examined through qualitative

analysis of the participants' responses to semi-structured interview questions regarding

development and maintenance of health anxiety. Study 1 was also used to collect

qualitative information from older participants on their experiences with CBT. A

secondary study was conducted to clarify the relationship between age and health anxiety.

The purpose of Study 2 was to examine differences between an older adult group and a

younger adult group control group with similar levels of health anxiety as measured by a

common measure of health anxiety. The goal was to examine whether the nature of the

two groups' concerns on various dimensions of health anxiety was comparable or

whether the pattern of responses differed. Specifically, the older adult and younger adult

53

Perspective-taking strategies

Demonstration videos

Mid-week troubleshooting

phone calls Weekly readings

Factors Affecting Seniors in Therapy

Possible Cognitive Decline Excessive Preoccupations

Medical and physical problems Social Isolation

Simplified terms

v

Weekly graphing of mood

Significant Improvement in Outcomes

Symptom Reduction Increased Therapeutic Alliance

Increased Motivation for Psychotherapy

Figure 2. Relationship between enhancements, factors affecting seniors in therapy, and

outcome in psychotherapy.

54

Perspective-taking strategies

Demonstration videos

Mid-week troubleshooting

phone calls

1 Factors Affecting Seniors in

Therapy

Possible Cognitive Decline Excessive Preoccupations

Medical and physical problems Social Isolation

Simplified terms

Weekly graphing of mood

Significant Improvement in Outcomes

Symptom Reduction Increased Therapeutic Alliance

Increased Motivation for Psychotherapy

Figure 2. Relationship between enhancements, factors affecting seniors in therapy, and

outcome in psychotherapy.

54

groups were matched on their overall level of health anxiety as assessed by the WI. This

allowed for examination of how the younger and older adults would differ on

subdimensions of health anxiety, such as bodily preoccupation, fear of disease, and

disease conviction. This study was felt to be important to address questions that exist in

the literature with regard to the impact of age on health anxiety.

1.10 Hypotheses

1.10.1 Hypotheses: Study 1

Based on the results of earlier investigations (e.g., Barsky & Ahern, 2004;

Mohlman et al., 2003), it was hypothesized that:

1. Participants receiving SCBT and ECBT, but not those in WLC, would evidence

improvements in health anxiety, frequency of hypochondriacal thoughts,

hypochondriacal somatic symptoms, tendency to experience bodily sensations as

distressing, state and trait anxiety, depression, pain, and health-related quality of

life from pre-treatment to post-treatment.

2. In keeping with the findings of Mohlman et al. (2003), participants treated with

ECBT would demonstrate the greatest overall improvement at post-treatment and

follow-up on each of the measures indicated in the first hypothesis in comparison

to SCBT and WLC.

3. For participants treated with each of SCBT and ECBT, all expected improvements

would be maintained three months following the conclusion of treatment.

4. Participants treated with ECBT would demonstrate a higher level of therapeutic

alliance at three and six weeks than those receiving SCBT.

55

groups were matched on their overall level of health anxiety as assessed by the WI. This

allowed for examination of how the younger and older adults would differ on

subdimensions of health anxiety, such as bodily preoccupation, fear of disease, and

disease conviction. This study was felt to be important to address questions that exist in

the literature with regard to the impact of age on health anxiety.

1.10 Hypotheses


Based on the results of earlier investigations (e.g., Barsky & Ahern, 2004;

Mohlman et al., 2003), it was hypothesized that:

1. Participants receiving SCBT and ECBT, but not those in WLC, would evidence

improvements in health anxiety, frequency of hypochondriacal thoughts,

hypochondriacal somatic symptoms, tendency to experience bodily sensations as

distressing, state and trait anxiety, depression, pain, and health-related quality of

life from pre-treatment to post-treatment.

2. In keeping with the findings of Mohlman et al. (2003), participants treated with

ECBT would demonstrate the greatest overall improvement at post-treatment and

follow-up on each of the measures indicated in the first hypothesis in comparison

to SCBT and WLC.

3. For participants treated with each of SCBT and ECBT, all expected improvements

would be maintained three months following the conclusion of treatment.

4. Participants treated with ECBT would demonstrate a higher level of therapeutic

alliance at three and six weeks than those receiving SCBT.

55

5. Participants treated with ECBT would demonstrate a higher level of motivation

for psychotherapy at three and six weeks than those receiving SCBT.

6. We did not make any hypotheses regarding the qualitative responses.


1. It was hypothesized that participants in the older group would have significantly

higher scores than the control group on the Somatic Symptoms/Bodily

Preoccupation subscale of the WI, the Negative Consequences of Illness subscale

of the SHAI, and the Symptoms Effects subscale of the IAS. There were no other

hypothesized differences on other subscales.

56

5. Participants treated with ECBT would demonstrate a higher level of motivation

for psychotherapy at three and six weeks than those receiving SCBT.

6. We did not make any hypotheses regarding the qualitative responses.


1. It was hypothesized that participants in the older group would have significantly

higher scores than the control group on the Somatic Symptoms/Bodily

Preoccupation subscale of the WI, the Negative Consequences of Illness subscale

of the SHAI, and the Symptoms Effects subscale of the IAS. There were no other

hypothesized differences on other subscales.

56

2. METHOD

2.1 Study 1

2.1.1 Participants

Recruitment of participants was accomplished through newspaper advertisements,

appearances by the author on radio and cable television programs, short information

presentations by the author to seniors' groups, and posted announcements in seniors'

centres (e.g., seniors' community residences, other community organizations) and

physicians' offices in Regina, Saskatchewan (see Appendix A). Participants were asked

to inquire about their eligibility to participate if they were experiencing anxiety or worry

about their health. Interested participants were screened first by telephone with a short

questionnaire (i.e., WI) assessing their level of health anxiety. Those participants with a

significant amount of health anxiety were then invited to participate in the study.

Inclusion criteria consisted of the following: (a) a score of 8 or higher on the WI, (b)

willingness to keep medication status stable while participating in the study (i.e., no

change in psychotropic medication type or increase in dose), (c) no evidence of suicidal

ideation, (d) no evidence of current substance abuse, (e) no evidence of current psychotic

condition, and (f) aged 60 years of age and older (Barsky & Ahern, 2004). A consent

form was presented to participants before they began any questionnaires or therapy (see

Appendix B). All participants were randomly assigned to one of three conditions (WLC,

SCBT, or ECBT).

Participants were recruited from September 2007 until April 2009. The

recruitment goal for this study was to obtain 93 participants (31 per treatment group) with

57

2. METHOD

2.1 Study 1

2.1.1 Participants

Recruitment of participants was accomplished through newspaper advertisements,

appearances by the author on radio and cable television programs, short information

presentations by the author to seniors' groups, and posted announcements in seniors'

centres (e.g., seniors' community residences, other community organizations) and

physicians' offices in Regina, Saskatchewan (see Appendix A). Participants were asked

to inquire about their eligibility to participate if they were experiencing anxiety or worry

about their health. Interested participants were screened first by telephone with a short

questionnaire (i.e., WI) assessing their level of health anxiety. Those participants with a

significant amount of health anxiety were then invited to participate in the study.

Inclusion criteria consisted of the following: (a) a score of 8 or higher on the WI, (b)

willingness to keep medication status stable while participating in the study (i.e., no

change in psychotropic medication type or increase in dose), (c) no evidence of suicidal

ideation, (d) no evidence of current substance abuse, (e) no evidence of current psychotic

condition, and (f) aged 60 years of age and older (Barsky & Ahern, 2004). A consent

form was presented to participants before they began any questionnaires or therapy (see

Appendix B). All participants were randomly assigned to one of three conditions (WLC,

SCBT, or ECBT).

Participants were recruited from September 2007 until April 2009. The

recruitment goal for this study was to obtain 93 participants (31 per treatment group) with

57

significantly elevated health anxiety (i.e., a score of 8 or higher on the WI). The sample

size was estimated using power analysis (Faul & Erfelder, 1992). Setting the significance

criterion at 0.01 and assuming a moderate effect size (0.30) based on previous studies

(e.g., Barksy & Ahern, 2004; Mohlman et al., 2003), estimations of sample size using

power analysis lead to the conclusion that approximately 93 participants were required to

achieve a generally acceptable power of 0.80 (Cohen, 1988).

A total of 110 potential participants responded to recruitment advertisements. Of

these individuals, 73 met eligibility criteria and initially agreed to participate in the study.

However, 19 participants later declined to participate prior to completing questionnaires

due to lack of interest, difficulty with the time commitment, and not wanting to engage in

therapy. Another three participants (two participants from the SCBT group and one from

the ECBT group) dropped-out before completing all the sessions. Thus, a total of 54

participants completed the study. Although the goal to recruit 93 participants was not

met, the number of individuals who completed the study is similar to a number of prior

research samples assessing the effectiveness of CBT for health anxiety (e.g., Bouman &

Visser, 1998; Clark et al., 1998; Seivewright et al., 2008; Visser & Bouman, 2001;

Warwick et al., 1996; Warwick & Marks, 1988).

In total, 19 participants in the SCBT group completed the treatment and two

dropped out; 17 participants in the ECBT group completed the treatment and one dropped

out; and all 18 WLC participants completed the study. Table 1 outlines the participants'

demographic information for each group. Independent samples t-tests (for age, number

of health conditions) and chi-square analyses (for sex, marital status, education level)

58

significantly elevated health anxiety (i.e., a score of 8 or higher on the WI). The sample

size was estimated using power analysis (Faul & Erfelder, 1992). Setting the significance

criterion at 0.01 and assuming a moderate effect size (0.30) based on previous studies

(e.g., Barksy & Ahern, 2004; Mohlman et al., 2003), estimations of sample size using

power analysis lead to the conclusion that approximately 93 participants were required to

achieve a generally acceptable power of 0.80 (Cohen, 1988).

A total of 110 potential participants responded to recruitment advertisements. Of

these individuals, 73 met eligibility criteria and initially agreed to participate in the study.

However, 19 participants later declined to participate prior to completing questionnaires

due to lack of interest, difficulty with the time commitment, and not wanting to engage in

therapy. Another three participants (two participants from the SCBT group and one from

the ECBT group) dropped-out before completing all the sessions. Thus, a total of 54

participants completed the study. Although the goal to recruit 93 participants was not

met, the number of individuals who completed the study is similar to a number of prior

research samples assessing the effectiveness of CBT for health anxiety (e.g., Bouman &

Visser, 1998; Clark et a l , 1998; Seivewright et al, 2008; Visser & Bouman, 2001;

Warwick et a l , 1996; Warwick & Marks, 1988).

In total, 19 participants in the SCBT group completed the treatment and two

dropped out; 17 participants in the ECBT group completed the treatment and one dropped

out; and all 18 WLC participants completed the study. Table 1 outlines the participants'

demographic information for each group. Independent samples t-tests (for age, number

of health conditions) and chi-square analyses (for sex, marital status, education level)

58

Table 1

Background Characteristics by Group

Characteristics SCBT

(n = 21)

ECBT

(n= 18)

WLC

(n = 18)

Total

(n = 57)

Age

Total Health Conditions

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

69.00 (6.81)

2.43 (1.50)

68.17 (6.84)

2.11 (1.18)

68.88 (7.47)

2.12 (1.54)

68.72 (6.92)

2.30 (1.46)

Number % Number % Number % Number %

Sex

Female 16 (76.2) 12 (66.7) 16 (88.9) 44 (77.2)

Male 5 (23.8) 6 (33.3) 2 (11.1) 13 (22.8)

Marital Status

Married/ 6 (28.6) 10 (55.6) 9 (50.0) 25 (43.9)

Common-Law

Not Married 15 (71.4) 8 (44.4) 9 (50.0) 32 (56.1)

Education

< High School 9 (42.9) 6 (33.3) 8 (44.4) 23 (40.3)

> = High School 12 (57.1) 12 (66.7) 10 (55.6) 34 (59.7)

Note. SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced Cognitive

Behavioural Therapy; WLC = Wait-List Control

59

Table 1

Background Characteristics by Group

Characteristics SCBT

(w = 21)

ECBT

(n=18)

WLC

(w=18)

Total

(n = 57)

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Age 69.00(6.81) 68.17(6.84) 68.88(7.47) 68.72 (6.92)

Total Health Conditions 2.43(1.50) 2.11(1.18) 2.12(1.54) 2.30(1.46)

Sex

Female

Male

Marital Status

Married/

Common-Law

Not Married

Education

< High School

> = High School

Number %

16(76.2)

5 (23.8)

6 (28.6)

15(71.4)

9 (42.9)

12(57.1)

Number %

12 (66.7)

6(33.3)

10 (55.6)

8 (44.4)

6 (33.3)

12 (66.7)

Number %

16 (88.9)

2(11.1)

9 (50.0)

9 (50.0)

8 (44.4)

10(55.6)

Number %

44 (77.2)

13 (22.8)

25 (43.9)

32(56.1)

23 (40.3)

34 (59.7)



59

were used to compare demographic information between groups. This showed no

differences in age, number of health conditions, sex, marital status, and education

between groups (see Table 2). A summary of participants' health conditions is presented

in Table 3. The most common conditions cited were arthritis (55.6%), high blood

pressure (44.4%), and osteoporosis (31.5%). Other common health conditions reported

included hearing problems, heart disease, vision problems, and respiratory disease.

2.1.2 Measures

Questionnaires were chosen to assess health anxiety, frequency of

hypochondriacal thoughts, hypochondriacal somatic symptoms, tendency to experience

bodily sensations as distressing, state and trait anxiety, anxiety sensitivity, depression,

pain, health-related quality of life, therapeutic alliance, and motivation for psychotherapy.

The questionnaires described below fall into three separate areas — primary outcome

measures, secondary outcome measures, and measures of therapeutic alliance and

motivation. Primary outcome measures are identified as those relating to health anxiety,

frequency of hypochondriacal thoughts, and hypochondriacal somatic symptoms (i.e.,

measures that are most directly related to health anxiety). Secondary outcome measures

are identified as those questionnaires relating to anxiety sensitivity, state and trait anxiety,

depression, pain, and health-related quality of life. The measures of therapeutic alliance

and motivation for psychotherapy relate to aspects of the therapist or therapy and

participant motivation for herapy. In addition, demographic information was collected

and all participants were invited to share their perceptions and experiences through open-

ended questions at pre-treatment and at post-treatment. As part of the pre-treatment

60

were used to compare demographic information between groups. This showed no

differences in age, number of health conditions, sex, marital status, and education

between groups (see Table 2). A summary of participants' health conditions is presented

in Table 3. The most common conditions cited were arthritis (55.6%), high blood

pressure (44.4%), and osteoporosis (31.5%). Other common health conditions reported

included hearing problems, heart disease, vision problems, and respiratory disease.

2.1.2 Measures

Questionnaires were chosen to assess health anxiety, frequency of


bodily sensations as distressing, state and trait anxiety, anxiety sensitivity, depression,

pain, health-related quality of life, therapeutic alliance, and motivation for psychotherapy.

The questionnaires described below fall into three separate areas - primary outcome

measures, secondary outcome measures, and measures of therapeutic alliance and

motivation. Primary outcome measures are identified as those relating to health anxiety,

frequency of hypochondriacal thoughts, and hypochondriacal somatic symptoms (i.e.,

measures that are most directly related to health anxiety). Secondary outcome measures

are identified as those questionnaires relating to anxiety sensitivity, state and trait anxiety,

depression, pain, and health-related quality of life. The measures of therapeutic alliance

and motivation for psychotherapy relate to aspects of the therapist or therapy and

participant motivation for herapy. In addition, demographic information was collected

and all participants were invited to share their perceptions and experiences through open-

ended questions at pre-treatment and at post-treatment. As part of the pre-treatment

60

Table 2

Comparisons of Background Characteristics Between Groups

Characteristics SCBT vs. ECBT SCBT vs. WLC ECBT vs. WLC

Age .71 .96 .76


Sex (male, female)

Marital Status (married, not

married)

Education (< high school, > —

high school)

.80 .55 .69

.51 .30 .11

1.69 1.30 .03*

.01* .22 .31

Note. Independent samples t-test values are given for "Age" and "Number of Health

Conditions. All other values are from Chi-square analyses. SCBT = Standard Cognitive

Behavioural Therapy; ECBT = Enhanced Cognitive Behavioural Therapy; WLC = Wait-

List Control; * p < .05

61

Table 2

Comparisons of Background Characteristics Between Groups

Characteristics

Age


Sex (male, female)

Marital Status (married, not

married)

Education (< high school, > =

high school)

SCBT vs. ECBT

.71

.80

.51

1.69

.01*

SCBT vs. WLC

.96

.55

.30

1.30

.22

ECBT ' vs. WLC

.76

.69

.11

.03*

.31

Note. Independent samples Mest values are given for "Age" and "Number of Health

Conditions. All other values are from Chi-square analyses. SCBT = Standard Cognitive

Behavioural Therapy; ECBT = Enhanced Cognitive Behavioural Therapy; WLC = Wait-

List Control; * p<.05

61

Table 3

Summary of Participants' Health Conditions by Group

Health Condition SCBT

(n = 21)

ECBT

(n = 18)

WLC

(n = 18)

Total

(n = 57)

Arthritis


10 (47.6) 8 (44.4) 12 (66.7) 32 (56.1)

Cancer 0 2 (11.1) 1 (5.6) 4 (7.0)

Diabetes 1 (4.8) 0 2 (11.1) 3 (5.3)

Hearing Problems 7 (33.3) 4 (22.2) 2 (11.1) 15 (26.3)

Heart Disease 4 (19.0) 2 (11.1) 4 (22.2) 10 (17.5)

High Blood Pressure 12 (21.1) 4 (22.2) 9 (50.0) 25 (43.9)

Kidney Disease 1 (4.8) 0 0 1 (1.8)

Osteoporosis 6 (28.6) 7 (38.9) 5 (27.8) 18 (31.66)

Parkinson's Disease 0 1 (5.6) 0 1 (1.8)

Respiratory Disease 3 (14.3) 1 (5.6) 4 (22.2) 8 (14.0)

Stroke 2 (9.5) 2 (11.1) 0 4 (7.0)

Vision Problems 4 (19.0) 4 (22.2) 3 (16.7) 11 (19.3)



62

Table 3


Health Condition SCBT ECBT WLC Total

(« = 21) (n =18) (w=18) (AI = 57)


Arthritis

Cancer

Diabetes

Hearing Problems

Heart Disease

High Blood Pressure

Kidney Disease

Osteoporosis

Parkinson's Disease

Respiratory Disease

Stroke

Vision Problems

10 (47.6)

0

1 (4.8)

7(33.3)

4(19.0)

12(21.1)

1 (4.8)

6 (28.6)

0

3 (14.3)

2 (9.5)

4 (19.0)

8 (44.4)

2(11.1)

0

4 (22.2)

2(11.1)

4 (22.2)

0

7 (38.9)

1 (5.6)

1 (5.6)

2(11.1)

4 (22.2)

12 (66.7)

1 (5.6)

2(11.1)

2(11.1)

4 (22.2)

9 (50.0)

0

5 (27.8)

0

4 (22.2)

0

3 (16.7)

32(56.1)

4 (7.0)

3 (5.3)

15 (26.3)

10(17.5)

25 (43.9)

1(1.8)

18(31.66)

1(1.8)

8 (14.0)

4 (7.0)

11(19.3)



62

questionnaire package, all participants were asked to respond in writing to the following

questions: (1) What are your previous illness experiences? During childhood? Family

members and friends affected?; (2) Why do you believe you worry about your health?;

(3) What do you do to cope with your worry?; and (4) With respect to your health, what

do you worry about? Participants who completed the SCBT and ECBT treatments were

also asked the following questions: (1) Do you feel the program helped improve your

worries about health? If so, how?; (2) What did you find most helpful about the

program?; (3) What did you find least helpful about the program?; (4) How did you feel

about your relationship with the therapist?; (5) In your opinion, was there anything about

the program that helped strengthen your relationship? If so, please explain.; (6) In your

opinion, was there anything about the therapist that helped strengthen your relationship?

If so, please explain.; (7) Did your motivation for doing the program change throughout

the sessions? If so, how and why do you think that is?; (8) In your opinion, was there

anything about the program that helped motivate you to try and practice some of the

techniques in the program? If so, please explain.; and (9) In your opinion, was there

anything about the therapist or what she did that helped motivate you to try and practice

some of the techniques in the program? If so, please explain. Open-ended questions

were included so participants could provide additional information, comments, feedback,

and experiences in a qualitative form. The Structured Clinical Interview for the DSM-IV

Axis I Disorders (SCID-I), Clinician Version (First, Spitzer, Gibbon, & Williams, 1996)

was administered to all participants during the initial assessment in order to accurately

63

questionnaire package, all participants were asked to respond in writing to the following

questions: (1) What are your previous illness experiences? During childhood? Family

members and friends affected?; (2) Why do you believe you worry about your health?;

(3) What do you do to cope with your worry?; and (4) With respect to your health, what

do you worry about? Participants who completed the SCBT and ECBT treatments were

also asked the following questions: (1) Do you feel the program helped improve your

worries about health? If so, how?; (2) What did you find most helpful about the

program?; (3) What did you find least helpful about the program?; (4) How did you feel

about your relationship with the therapist?; (5) In your opinion, was there anything about

the program that helped strengthen your relationship? If so, please explain.; (6) In your

opinion, was there anything about the therapist that helped strengthen your relationship?

If so, please explain.; (7) Did your motivation for doing the program change throughout

the sessions? If so, how and why do you think that is?; (8) In your opinion, was there

anything about the program that helped motivate you to try and practice some of the

techniques in the program? If so, please explain.; and (9) In your opinion, was there

anything about the therapist or what she did that helped motivate you to try and practice

some of the techniques in the program? If so, please explain. Open-ended questions

were included so participants could provide additional information, comments, feedback,

and experiences in a qualitative form. The Structured Clinical Interview for the DSM-IV

Axis I Disorders (SCID-I), Clinician Version (First, Spitzer, Gibbon, & Williams, 1996)

was administered to all participants during the initial assessment in order to accurately

63

assess the participants' backgrounds, history, and current difficulties. This was not used

in the analyses.

2.1.2.1 Primary Outcome Measures

Whiteley Index (WI; Pilowsky, 1967). The WI was developed to assess the core

features of hypochondriasis. Respondents answer 'yes' or 'no' to each of 14 questions,

including items such as "Do you often worry about the possibility that you have a serious

illness?" and "Is it hard for you to believe the doctor when he tells you there is nothing to

worry about?" In the original paper on the measure, Pilowsky (1967) reported that

principal components analysis of the WI items yielded three factors: (1) disease fear,

which refers to the fear of having or developing a serious illness; (2) disease conviction,

which describes the subjective impression of the patient as suffering from multiple bodily

symptoms and pains; and (3) bodily preoccupation, which is said to represent the strength

of the patients' belief that they suffer from a serious illness. To score the measure, the

three subscales can be scored separately or summed to yield a total score. Its test-retest

reliability and discriminant and convergent validity have been established (Beaber &

Rodney, 1984; Hanback & Revelle, 1978; Pilowsky, 1967, 1978). The intrascale

consistency of the WI among a sample of general medical outpatients was 0.85

(Cronbach alpha), and the test-retest reliability was 0.84 (Pearson's product-moment

correlation) over a mean interval of 25.6 days (Barsky, Wyshak, & Klerman, 1990c).

The WI predicts both treatment outcome and health care utilization (Barsky, Cleary,

Wyshak, Spitzer, Williams, & Klerman, 1992).

64

assess the participants' backgrounds, history, and current difficulties. This was not used

in the analyses.

2.1.2.1 Primary Outcome Measures

Whiteley Index (WI; Pilowsky, 1967). The WI was developed to assess the core

features of hypochondriasis. Respondents answer 'yes' or 'no' to each of 14 questions,

including items such as "Do you often worry about the possibility that you have a serious

illness?" and "Is it hard for you to believe the doctor when he tells you there is nothing to

worry about?" In the original paper on the measure, Pilowsky (1967) reported that

principal components analysis of the WI items yielded three factors: (1) disease fear,

which refers to the fear of having or developing a serious illness; (2) disease conviction,

which describes the subjective impression of the patient as suffering from multiple bodily

symptoms and pains; and (3) bodily preoccupation, which is said to represent the strength

of the patients' belief that they suffer from a serious illness. To score the measure, the

three subscales can be scored separately or summed to yield a total score. Its test-retest

reliability and discriminant and convergent validity have been established (Beaber &

Rodney, 1984; Hanback & Revelle, 1978; Pilowsky, 1967, 1978). The intrascale

consistency of the WI among a sample of general medical outpatients was 0.85

(Cronbach alpha), and the test-retest reliability was 0.84 (Pearson's product-moment

correlation) over a mean interval of 25.6 days (Barsky, Wyshak, & Klerman, 1990c).

The WI predicts both treatment outcome and health care utilization (Barsky, Cleary,

Wyshak, Spitzer, Williams, & Klerman, 1992).

64

Hiller, Rief, and Fichter (2002) determined that a cut-off score of 8 provided

optimal sensitivity (71% of hypochondriacal patients correctly identified) and specificity

(80% of controls correctly identified) for determining cases of hypochondriasis versus

non-hypochondriacal cases. The WI has demonstrated good psychometric properties

when used to assess hypochondriasis in a broad-aged sample that included older adult

patients (Barsky, Frank, Cleary, et al., 1991). Specific psychometric data for this

measure exclusively with older adults was not reported.

Despite favorable psychometric properties, the factor structure of the WI has not

been found to be robust across studies (Asmundson, Carleton, Bovell, & Taylor, 2008).

In a study examining the factor analysis of the WI, Asmundson et al. (2008) reviewed a

number of published studies examining the factor structure of the WI in clinical samples

using exploratory factor-analytic (EFA) procedures (Asmundson et al., 2008; Hiller, Rief,

& Fichter, 2002; Pilowsky, 1967; Speckens, Spinhoven, Sloekers, Bolk, & van Hemert,

1996), confirmatory factor analytic (CFA) procedures (Conradt, Cavanaugh, Franklin, &

Rief, 2006), and a combination of both EFA and CFA procedures (Fink et al., 1999).

Varying results were found. Asmundson et al. (2008) suggested that the inconsistent

findings are likely the result of these studies using different practices with regard to factor

identification and item retention. Moreover, differences in factor solutions may have

resulted from using samples that differed significantly with respect to range and severity

of health anxiety. Asmundson et al. (2008) then tested a total of nine different models

that have been found in past research on a sample of 300 undergraduate students. They

concluded that the greatest support was found for a two-factor solution with three items

65

Hiller, Rief, and Fichter (2002) determined that a cut-off score of 8 provided

optimal sensitivity (71% of hypochondriacal patients correctly identified) and specificity

(80% of controls correctly identified) for determining cases of hypochondriasis versus

non-hypochondriacal cases. The WI has demonstrated good psychometric properties

when used to assess hypochondriasis in a broad-aged sample that included older adult

patients (Barsky, Frank, Cleary, et al., 1991). Specific psychometric data for this

measure exclusively with older adults was not reported.

Despite favorable psychometric properties, the factor structure of the WI has not

been found to be robust across studies (Asmundson, Carleton, Bovell, & Taylor, 2008).

In a study examining the factor analysis of the WI, Asmundson et al. (2008) reviewed a

number of published studies examining the factor structure of the WI in clinical samples

using exploratory factor-analytic (EFA) procedures (Asmundson et al., 2008; Hiller, Rief,

& Fichter, 2002; Pilowsky, 1967; Speckens, Spinhoven, Sloekers, Bolk, & van Hemert,

1996), confirmatory factor analytic (CFA) procedures (Conradt, Cavanaugh, Franklin, &

Rief, 2006), and a combination of both EFA and CFA procedures (Fink et al., 1999).

Varying results were found. Asmundson et al. (2008) suggested that the inconsistent

findings are likely the result of these studies using different practices with regard to factor

identification and item retention. Moreover, differences in factor solutions may have

resulted from using samples that differed significantly with respect to range and severity

of health anxiety. Asmundson et al. (2008) then tested a total of nine different models

that have been found in past research on a sample of 300 undergraduate students. They

concluded that the greatest support was found for a two-factor solution with three items

65

on each factor. These factors were labelled Somatic Symptoms/Bodily Preocupation and

Disease Worry/Phobia.

In this study, following past researchers, we calculated the total score of the WI

and used a cut off score of eight to identify individuals with significant health anxiety

(Hiller et al., 2002). In analyses of patient outcomes we examined both the total score

and the two subscale scores identified by Asmundson et al. (2008).

Short Form Health Anxiety Inventory (SHAI; Salkovskis et al., 2002). The SHAI

was designed to be a comprehensive measure for anxiety about health across the

continuum of symptom severity (Salkovskis et al., 2002). The inventory can be given to

patients with medical problems and used to distinguish these individuals from those with

other anxiety-based disorders. The 18 items comprising the short form of this scale are

closely aligned with the model of health anxiety proposed by Warwick and Salkovskis

(1990). To complete this inventory, individuals are asked for each item to choose one of

four statements that most closely resembles their thoughts and feelings (there is the

option to choose more than one statement). Response choices are then scored from 0 to 3

(if multiple responses were selected on an item, the highest score is used for total score

computation) and summed to form a total score. Subscales include a negative

consequences scale that assesses differences between individual perceptions of the

negative consequences of illness and a general scale reflecting key aspects of health

anxiety (i.e., disease conviction, perceived vulnerability to illness, fear and worry about

illness, preoccupation, interference and bodily awareness, psychological reactions to

66

on each factor. These factors were labelled Somatic Symptoms/Bodily Preocupation and

Disease Worry/Phobia.

In this study, following past researchers, we calculated the total score of the WI

and used a cut off score of eight to identify individuals with significant health anxiety

(Hiller et al., 2002). In analyses of patient outcomes we examined both the total score

and the two subscale scores identified by Asmundson et al. (2008).

Short Form Health Anxiety Inventory (SHAI; Salkovskis et al., 2002). The SHAI

was designed to be a comprehensive measure for anxiety about health across the

continuum of symptom severity (Salkovskis et al., 2002). The inventory can be given to

patients with medical problems and used to distinguish these individuals from those with

other anxiety-based disorders. The 18 items comprising the short form of this scale are

closely aligned with the model of health anxiety proposed by Warwick and Salkovskis

(1990). To complete this inventory, individuals are asked for each item to choose one of

four statements that most closely resembles their thoughts and feelings (there is the

option to choose more than one statement). Response choices are then scored from 0 to 3

(if multiple responses were selected on an item, the highest score is used for total score

computation) and summed to form a total score. Subscales include a negative

consequences scale that assesses differences between individual perceptions of the

negative consequences of illness and a general scale reflecting key aspects of health

anxiety (i.e., disease conviction, perceived vulnerability to illness, fear and worry about

illness, preoccupation, interference and bodily awareness, psychological reactions to

66

bodily sensations, deliberate action after a bodily sensation, concerns about death,

attitudes of self and others towards health anxiety, avoidance and reassurance).

A cut-off score of 18 or higher has been used to identify individuals who have a

high likelihood of having a DSM-IV diagnosis of hypochondriasis. Cut-off scores

between 15 and 17 identify individuals who have been found to be highly health anxious

but who are not likely to meet clinical criteria for a diagnosis of hypochondriasis. Scores

lying between 15 and 17 have been found to be three standard deviations above norms of

non-clinical controls (Rode et al., 2006).

The scale has good internal consistency, alpha equal to .89, when administered to

a sample of individuals diagnosed with hypochondriasis, anxious controls (i.e., panic

disorder and social phobia), non-clinical controls, general practice clinic clients, and

medical outpatients (Salkovskis et al., 2002). Assessment of the test-retest reliability of

the full version of the scale produced a correlation of .76 with on average a 22-day

interval between questionnaire completion dates. Discrimination between scores from

individuals with hypochondriasis or anxious controls and non-clinical or medical patients

was significant (Salkovskis et al., 2002). Responsiveness to treatment progress was

demonstrated by a significantly greater change in full scale (Salkovskis et al., 2002) and

short form (Barsky & Ahern, 2004) scores among a group of patients actively engaged in

treatment versus a group awaiting treatment using the full scale (Salkovskis et al., 2002)

and the short form (Barsky & Ahern, 2004). Specific psychometric data for this measure

exclusively with older adults is not yet available. Boston and Merrick (2010) used the

SHAI to assess health anxiety in an older adult sample, but did not report any

67

bodily sensations, deliberate action after a bodily sensation, concerns about death,

attitudes of self and others towards health anxiety, avoidance and reassurance).

A cut-off score of 18 or higher has been used to identify individuals who have a

high likelihood of having a DSM-IV diagnosis of hypochondriasis. Cut-off scores

between 15 and 17 identify individuals who have been found to be highly health anxious

but who are not likely to meet clinical criteria for a diagnosis of hypochondriasis. Scores

lying between 15 and 17 have been found to be three standard deviations above norms of

non-clinical controls (Rode et al., 2006).

The scale has good internal consistency, alpha equal to .89, when administered to

a sample of individuals diagnosed with hypochondriasis, anxious controls (i.e., panic

disorder and social phobia), non-clinical controls, general practice clinic clients, and

medical outpatients (Salkovskis et al., 2002). Assessment of the test-retest reliability of

the full version of the scale produced a correlation of .76 with on average a 22-day

interval between questionnaire completion dates. Discrimination between scores from

individuals with hypochondriasis or anxious controls and non-clinical or medical patients

was significant (Salkovskis et al., 2002). Responsiveness to treatment progress was

demonstrated by a significantly greater change in full scale (Salkovskis et al., 2002) and

short form (Barsky & Ahern, 2004) scores among a group of patients actively engaged in

treatment versus a group awaiting treatment using the full scale (Salkovskis et al., 2002)

and the short form (Barsky & Ahern, 2004). Specific psychometric data for this measure

exclusively with older adults is not yet available. Boston and Merrick (2010) used the

SHAI to assess health anxiety in an older adult sample, but did not report any

67

psychometric properties. Moreover, because the inventory can be given to patients with

medical problems and used to distinguish these individuals from those with other anxiety-

based disorders, it was chosen for this study.

Factor analysis of the scale by Salkovskis et al. (2002) confirmed the two

previously identified subscales. However, subsequent factor analyses have produced

different results; this may reflect differences in subsamples. Abramowitz et al. (2007),

for instance, conducted an EFA with the 18-item SHAI using a sample of 442 students.

A three-factor solution was determined, with the factors labeled as Illness Likelihood,

Illness Severity, and Body Vigilance. Olatunji (2009) conducted a second EFA using

principal components analysis with a sample of 498 students. Again, an interpretable

three factor solution was indicated and Olatunji (2009) retained the same factor labels as

those identified by Abramowitz et al. (2007), with only slight variations in the items

contained within each factor. Illness Likelihood assesses the intrusive cognitions about

health beliefs about the probability of acquiring a serious illness, Illness Severity

measures the perceived burden of having serious illness, and Body Vigilance assesses

attention towards bodily sensations.

A CFA was conducted to test the goodness-of-fit of three competing models of

the latent structure of the SHAI (Abramowitz et al., 2007). The single-factor model

provided a poor fit to the data, whereas the two- and three-factor models were identified

as having adequate and similar model fit. As a result, the authors recommended the two-

factor model reported by Salkovskis et al. (2002) on the basis of parsimony, labeling their

factors Illness Likelihood and Negative Consequences. Illness Likelihood comprised 14

68

psychometric properties. Moreover, because the inventory can be given to patients with

medical problems and used to distinguish these individuals from those with other anxiety-

based disorders, it was chosen for this study.

Factor analysis of the scale by Salkovskis et al. (2002) confirmed the two

previously identified subscales. However, subsequent factor analyses have produced

different results; this may reflect differences in subsamples. Abramowitz et al. (2007),

for instance, conducted an EFA with the 18-item SHAI using a sample of 442 students.

A three-factor solution was determined, with the factors labeled as Illness Likelihood,

Illness Severity, and Body Vigilance. Olatunji (2009) conducted a second EFA using

principal components analysis with a sample of 498 students. Again, an interpretable

three factor solution was indicated and Olatunji (2009) retained the same factor labels as

those identified by Abramowitz et al. (2007), with only slight variations in the items

contained within each factor. Illness Likelihood assesses the intrusive cognitions about

health beliefs about the probability of acquiring a serious illness, Illness Severity

measures the perceived burden of having serious illness, and Body Vigilance assesses

attention towards bodily sensations.

A CFA was conducted to test the goodness-of-fit of three competing models of

the latent structure of the SHAI (Abramowitz et al., 2007). The single-factor model

provided a poor fit to the data, whereas the two- and three-factor models were identified

as having adequate and similar model fit. As a result, the authors recommended the two-

factor model reported by Salkovskis et al. (2002) on the basis of parsimony, labeling their

factors Illness Likelihood and Negative Consequences. Illness Likelihood comprised 14

68

items concerning beliefs about the likelihood of developing a serious illness and focus on

bodily sensations and the four items of the Negative Consequences factor measured

catastrophic cognitions about the burden and outcome of having a serious medical

condition. Based on this research, we also chose to calculate the SHAI subscales as

outlined by Salkvoskis et al. (2002).

Illness Attitudes Scale (IAS; Kellner, 1986; Kellner et al., 1987). The IAS is a 29-

item self-report questionnaire assessing fears, beliefs, and attitudes associated with health

anxiety. It is comprised of nine subscales, each assessing aspects of abnormal illness

behaviour and beliefs including 1) worry about illness, 2) concerns about pain, 3) health

habits, 4) hypochondriacal beliefs, 5) thanatophobia, 6) disease phobia, 7) bodily

preoccupations, 8) treatment experiences, and 9) effects of symptoms. Each scale is

comprised of three items ranked on a 5-point scale with endpoints labelled 'no' (0) and

`most of the time' (4). A score, ranging from 0 to a maximum of 108, is calculated for

the IAS by summing all responses. Higher scores reflect greater health anxiety. Two

additional questions ask the respondent for further information about illness and

treatment, but they are not calculated in the scoring of the scale.

Factor analyses of the IAS using various populations have revealed that the

original factor solution outlined by Kellner et al. (1987) may not be the most suitable fit

for the IAS items. Varying models have emerged including two-factor, four-factor, and

five-factor solutions. Hiller et al. (2002), Speckens et al. (1996), and Wise and Sheridan

(2001) all found similar two-factor solutions. Speckens et al. (1996) conducted an EFA

using principal components analysis with 130 general medical outpatients, 113 general

69

items concerning beliefs about the likelihood of developing a serious illness and focus on

bodily sensations and the four items of the Negative Consequences factor measured

catastrophic cognitions about the burden and outcome of having a serious medical

condition. Based on this research, we also chose to calculate the SHAI subscales as

outlined by Salkvoskis et al. (2002).

Illness Attitudes Scale (IAS; Kellner, 1986; Kellner et al., 1987). The IAS is a 29-

item self-report questionnaire assessing fears, beliefs, and attitudes associated with health

anxiety. It is comprised of nine subscales, each assessing aspects of abnormal illness

behaviour and beliefs including 1) worry about illness, 2) concerns about pain, 3) health

habits, 4) hypochondriacal beliefs, 5) thanatophobia, 6) disease phobia, 7) bodily

preoccupations, 8) treatment experiences, and 9) effects of symptoms. Each scale is

comprised of three items ranked on a 5-point scale with endpoints labelled 'no' (0) and

'most of the time' (4). A score, ranging from 0 to a maximum of 108, is calculated for

the IAS by summing all responses. Higher scores reflect greater health anxiety. Two

additional questions ask the respondent for further information about illness and

treatment, but they are not calculated in the scoring of the scale.

Factor analyses of the IAS using various populations have revealed that the

original factor solution outlined by Kellner et al. (1987) may not be the most suitable fit

for the IAS items. Varying models have emerged including two-factor, four-factor, and

five-factor solutions. Hiller et al. (2002), Speckens et al. (1996), and Wise and Sheridan

(2001) all found similar two-factor solutions. Speckens et al. (1996) conducted an EFA

using principal components analysis with 130 general medical outpatients, 113 general

69

practice patients, and 204 participants from the general population. The two factors

identified were labelled Health Anxiety and Illness Behaviour (Speckens et al., 1996).

Dammen et al. (1999) conducted an EFA using principal components analysis with 199

patients referred to cardiological outpatient investigation because of chest pain. Dammen

et al.'s (1999) two factors identified were also labelled Health Anxiety and Illness

Behaviour. Hiller et al. (2002) conducted an EFA using principal components analysis

with 570 patients with mental and psychophysiological disorders. Again, similar to

Speckens et al. (1996), the two factors found by Hiller et al. (2002) were labelled Health

Anxiety and Illness Behaviour.

Studies concluding that a four-factor solution provided the best fit for the items

include Ferguson and Daniel (1995), Hadjistavropoulos et al. (1999), and Stewart and

Watt (2000). Ferguson and Daniel (1995) conducted an EFA using principal components

analysis in a sample of 101 undergraduate students. Ferguson and Daniel's (1995) four

factors were named (1) General Hypochondriacal Fears and Beliefs, (2) Symptom

Experience and Frequency of Treatment, (3) Thanatophobia, and (4) Fear of Coronary

Heart Disease and Associated Health Habits. Hadjistavropoulos et al. (1999) conducted,

in two parts, a factor analysis of the IAS. In Study 1, they used principal components

analysis with a sample of 390 undergraduate students. In Study 2, Hadjistavropoulos et

al. (1999) employed CFA to compare seven different factor models of the IAS with the

sample of undergraduate students. Based on the results of the CFA, as well as previous

research and theoretical considerations, Hadjistavropoulos et al. (1999) concluded that a

four factor solution received the greatest support and could be conceptualized as

70

practice patients, and 204 participants from the general population. The two factors

identified were labelled Health Anxiety and Illness Behaviour (Speckens et al., 1996).

Dammen et al. (1999) conducted an EFA using principal components analysis with 199

patients referred to cardiological outpatient investigation because of chest pain. Dammen

et al.'s (1999) two factors identified were also labelled Health Anxiety and Illness

Behaviour. Hiller et al. (2002) conducted an EFA using principal components analysis

with 570 patients with mental and psychophysiological disorders. Again, similar to

Speckens et al. (1996), the two factors found by Hiller et al. (2002) were labelled Health

Anxiety and Illness Behaviour.

Studies concluding that a four-factor solution provided the best fit for the items

include Ferguson and Daniel (1995), Hadjistavropoulos et al. (1999), and Stewart and

Watt (2000). Ferguson and Daniel (1995) conducted an EFA using principal components

analysis in a sample of 101 undergraduate students. Ferguson and Daniel's (1995) four

factors were named (1) General Hypochondriacal Fears and Beliefs, (2) Symptom

Experience and Frequency of Treatment, (3) Thanatophobia, and (4) Fear of Coronary

Heart Disease and Associated Health Habits. Hadjistavropoulos et al. (1999) conducted,

in two parts, a factor analysis of the IAS. In Study 1, they used principal components

analysis with a sample of 390 undergraduate students. In Study 2, Hadjistavropoulos et

al. (1999) employed CFA to compare seven different factor models of the IAS with the

sample of undergraduate students. Based on the results of the CFA, as well as previous

research and theoretical considerations, Hadjistavropoulos et al. (1999) concluded that a

four factor solution received the greatest support and could be conceptualized as

70

hierarchical in nature, with four lower-order factors loading on a single higher-order

factor. The factors were labelled (1) Fear of Illness and Pain, (2) Symptom Effects, (3)

Treatment Experiences, and (4) Disease Conviction (Hadjistavropoulos et al., 1999).

Stewart and Watt (2000) presented an EFA using principal components analysis with a

sample of 197 undergraduate students. Similar to Hadjistavropoulos et al. (1999),

examination of the results revealed that a four-factor solution at the lower-order level

(with lower-order dimensions tapping illness-related Fears, Behaviour, Beliefs and

Effects), and a unifactorial measure at the higher-order level (i.e., higher-order dimension

tapping General Hypochondriacal Concerns) provided the best fit for the data.

Two studies found that a five-factor solution best fit the IAS items.

Hadjistavropoulos and Asmundson (1998) conducted an EFA using principal components

analysis with a sample of 198 chronic pain patients. The factors were named (1) Fear of

Illness and Pain, (2) Effects of Symptoms, (3) Health Habits, and (4) Disease Phobia and

Conviction, and (5) Fear of Death. Cox et al. (2000) conducted an EFA using principal

components analysis with a sample of 309 undergraduate students. Cox et al. (2000) also

produced a five-factor solution. The five factors identified were named (1) Fear of Illness

and Death, (2) Treatment Experience, (3) Symptom Effects, (4) Disease Phobia and

Conviction, and (5) Health Habits.

Of the above-reviewed studies, the highest quality study appears to have been

conducted by Hadjistavropoulos et al. (1999), who conducted the factor analysis with a

sample of 390 undergraduate students, and employed EFA and CFA procedures, with

comparison of various models. Thus, in the analyses of patient outcomes, we examined

71

hierarchical in nature, with four lower-order factors loading on a single higher-order

factor. The factors were labelled (1) Fear of Illness and Pain, (2) Symptom Effects, (3)

Treatment Experiences, and (4) Disease Conviction (Hadjistavropoulos et al., 1999).

Stewart and Watt (2000) presented an EFA using principal components analysis with a

sample of 197 undergraduate students. Similar to Hadjistavropoulos et al. (1999),

examination of the results revealed that a four-factor solution at the lower-order level

(with lower-order dimensions tapping illness-related Fears, Behaviour, Beliefs and

Effects), and a unifactorial measure at the higher-order level (i.e., higher-order dimension

tapping General Hypochondriacal Concerns) provided the best fit for the data.

Two studies found that a five-factor solution best fit the IAS items.

Hadjistavropoulos and Asmundson (1998) conducted an EFA using principal components

analysis with a sample of 198 chronic pain patients. The factors were named (1) Fear of

Illness and Pain, (2) Effects of Symptoms, (3) Health Habits, and (4) Disease Phobia and

Conviction, and (5) Fear of Death. Cox et al. (2000) conducted an EFA using principal

components analysis with a sample of 309 undergraduate students. Cox et al. (2000) also

produced a five-factor solution. The five factors identified were named (1) Fear of Illness

and Death, (2) Treatment Experience, (3) Symptom Effects, (4) Disease Phobia and

Conviction, and (5) Health Habits.

Of the above-reviewed studies, the highest quality study appears to have been

conducted by Hadjistavropoulos et al. (1999), who conducted the factor analysis with a

sample of 390 undergraduate students, and employed EFA and CFA procedures, with

comparison of various models. Thus, in the analyses of patient outcomes, we examined

71

both the total score and the four subscales on the IAS identified by Hadjistavropoulos et

al. (1999).

Researchers have also examined the sensitivity and specificity of the scale and

determined that a cut-off point of 45 maximized the precision of the scale (Cox et al.,

2000). Sensitivity equalled 72% and specificity equalled 73% when distinguishing

hypochondriacal patients from patients with other somatoform disorders, and specificity

climbing to 79% when the controls had psychiatric conditions other than somatoform

disorders. In an alternate sample of 246 medical outpatients, sensitivity and specificity

remained high at 79% and 84%, respectively (Speckens, van Hemert, Spinhoven, & Bolk,

1996). These findings are interpreted to mean that the IAS has acceptable levels of

sensitivity and specificity and thereby is susceptible to only low frequencies of Type I

and Type II errors. The scale has also been found to discern advances in treatment (Cox

et al., 2000). Among seniors aged 65 years and over, the internal consistency coefficient

(a) of the total scale has ranged from 0.84 to 0.85 (Bourgault-Fagnou &

Hadjistavropoulos, 2009; Bravo & Silverman, 2001).

Somatic Symptom Inventory (SSI; Barsky, Wyshak, & Klerman, 1986a and b).

The SSI is a 26-item questionnaire assessing somatic symptoms or bodily complaints

often associated with hypochondriasis. In this inventory, the patients' degree of

discomfort for each symptom is rated on 5-point linear scales (`not at all,' a little bit,'

`moderately,' quite a bit,' and 'a great deal'). The items were derived from the MMPI

hypochondriasis scale and the Symptom Checklist-90 somatization subscale. Among

medical outpatients, scores on this instrument have been found to correlate moderately (r

72

both the total score and the four subscales on the IAS identified by Hadjistavropoulos et

al. (1999).

Researchers have also examined the sensitivity and specificity of the scale and

determined that a cut-off point of 45 maximized the precision of the scale (Cox et al.,

2000). Sensitivity equalled 72% and specificity equalled 73%) when distinguishing

hypochondriacal patients from patients with other somatoform disorders, and specificity

climbing to 79% when the controls had psychiatric conditions other than somatoform

disorders. In an alternate sample of 246 medical outpatients, sensitivity and specificity

remained high at 79% and 84%, respectively (Speckens, van Hemert, Spinhoven, & Bolk,

1996). These findings are interpreted to mean that the IAS has acceptable levels of

sensitivity and specificity and thereby is susceptible to only low frequencies of Type I

and Type II errors. The scale has also been found to discern advances in treatment (Cox

et al., 2000). Among seniors aged 65 years and over, the internal consistency coefficient

(a) of the total scale has ranged from 0.84 to 0.85 (Bourgault-Fagnou &

Hadjistavropoulos, 2009; Bravo & Silverman, 2001).

Somatic Symptom Inventory (SSI; Barsky, Wyshak, & Klerman, 1986a and b).

The SSI is a 26-item questionnaire assessing somatic symptoms or bodily complaints

often associated with hypochondriasis. In this inventory, the patients' degree of

discomfort for each symptom is rated on 5-point linear scales ('not at all,' 'a little bit,'

'moderately,' 'quite a bit,' and 'a great deal'). The items were derived from the MMPI

hypochondriasis scale and the Symptom Checklist-90 somatization subscale. Among

medical outpatients, scores on this instrument have been found to correlate moderately (r

72

= 0.52 — 0.65) with those of the WI (Barsky et al., 1995; Noyes et al., 2003). The scale

also has been found to be significantly correlated with depressive symptoms and

utilization of medical services in a general medical outpatient setting (Barsky et al.,

1986a; Barsky et al., 1986b). Among a sample of 75 general medical clinic patients, the

SSI had a test-retest reliability of 0.86, and an internal consistency of 0.95. The SSI has

demonstrated good psychometric properties when used to assess hypochondriasis in a

broad-aged sample that included older adult patients (Barsky et al., 1991). Specific

psychometric data for this measure exclusively with older adults was not reported.

However, the SSI has demonstrated strong intercorrelations with the WI and together the

two measures accurately identify hyponchondriacal patients in medical settings (Barsky

et al., 1986).

Somatosensory Amplification Scale (SSAS; Barksy, Wyshak, & Klerman, 1990b).

The SSAS is a 10-item self-report questionnaire designed to measure the tendency to

experience bodily sensations as being unusually intense, aversive, or distressing. The

scale assesses the individual's sensitivity to a range of mild bodily experiences (e.g.,

hunger contractions), which are uncomfortable and unpleasant, but are not typical

symptoms of disease. The SSAS asks the respondent to indicate the degree to which each

statement is characteristic of them in general, on an ordinal scale from 1 (`not at all') to 5

(`extremely'). Internal consistency values for this scale have ranged from alpha = .71 to

.82, and test-retest reliability coefficients have ranged from r = 0.87 (4 weeks) to 0.79 (10

weeks) (Barsky et al., 1990b; Speckens, van Hemert, Spinhoven, & Bolk, 1996). SSAS

scores have been shown to be highly correlated with IAS and WI scores, indicating

73

= 0.52 - 0.65) with those of the WI (Barsky et al., 1995; Noyes et al., 2003). The scale

also has been found to be significantly correlated with depressive symptoms and

utilization of medical services in a general medical outpatient setting (Barsky et al.,

1986a; Barsky et al., 1986b). Among a sample of 75 general medical clinic patients, the

SSI had a test-retest reliability of 0.86, and an internal consistency of 0.95. The SSI has

demonstrated good psychometric properties when used to assess hypochondriasis in a

broad-aged sample that included older adult patients (Barsky et al., 1991). Specific

psychometric data for this measure exclusively with older adults was not reported.

However, the SSI has demonstrated strong intercorrelations with the WI and together the

two measures accurately identify hyponchondriacal patients in medical settings (Barsky

eta l , 1986).

Somatosensory Amplification Scale (SSAS; Barksy, Wyshak, & Klerman, 1990b).

The SSAS is a 10-item self-report questionnaire designed to measure the tendency to

experience bodily sensations as being unusually intense, aversive, or distressing. The

scale assesses the individual's sensitivity to a range of mild bodily experiences (e.g.,

hunger contractions), which are uncomfortable and unpleasant, but are not typical

symptoms of disease. The SSAS asks the respondent to indicate the degree to which each

statement is characteristic of them in general, on an ordinal scale from 1 ('not at all') to 5

('extremely'). Internal consistency values for this scale have ranged from alpha = .71 to

.82, and test-retest reliability coefficients have ranged from r = 0.87 (4 weeks) to 0.79 (10

weeks) (Barsky et al., 1990b; Speckens, van Hemert, Spinhoven, & Bolk, 1996). SSAS

scores have been shown to be highly correlated with IAS and WI scores, indicating

73

convergent validity (Speckens, van Hemert, Spinhoven, & Bolk, 1996). Responsiveness

to treatment progress was demonstrated by a significant reduction of SSAS scores among

a group of patients actively engaged in treatment versus a group awaiting treatment

(Barsky & Ahern, 2004). Specific psychometric data for this measure exclusively with

older adults has not been reported.

Hypochondriacal Cognitions Questionnaire (Barsky & Ahern, 2004). This two-

part, 36-item measure was designed to assess frequency of hypochondriacal thoughts. In

Part I, the patient is required to rate how often each of the 18 disease-related thoughts

occurs on a 5-point scale (`thought never occurs,' thought rarely occurs,' thought occurs

during half of the times when I am nervous or concerned,' thought usually occurs,' and

`thought always occurs'). In Part II, the patient is required to rate how often each of the

same 18 disease-related thoughts occurs on a scale from 0-100 CI do not believe this

thought at all' to 'I am completely convinced this thought is true'). The individual items

in each part can be summed to get the overall score. Only Part I was used in this study.

Responsiveness to treatment progress was demonstrated by a significant reduction of

hypochondriacal thought frequency among a group of patients actively engaged in

treatment versus a group awaiting treatment (Barsky & Ahern, 2004). Specific

psychometric data for this measure exclusively with older adults has not been reported.

As this appeared to be the only measure available at the time that assessed

hypochondriacal cognitions, it was chosen for this study.

74

convergent validity (Speckens, van Hemert, Spinhoven, & Bolk, 1996). Responsiveness

to treatment progress was demonstrated by a significant reduction of SSAS scores among

a group of patients actively engaged in treatment versus a group awaiting treatment

(Barsky & Ahern, 2004). Specific psychometric data for this measure exclusively with

older adults has not been reported.

Hypochondriacal Cognitions Questionnaire (Barsky & Ahern, 2004). This two-

part, 36-item measure was designed to assess frequency of hypochondriacal thoughts. In

Part I, the patient is required to rate how often each of the 18 disease-related thoughts

occurs on a 5-point scale ('thought never occurs,' 'thought rarely occurs,' 'thought occurs

during half of the times when I am nervous or concerned,' 'thought usually occurs,' and

'thought always occurs'). In Part II, the patient is required to rate how often each of the

same 18 disease-related thoughts occurs on a scale from 0-100 (T do not believe this

thought at all' to T am completely convinced this thought is true'). The individual items

in each part can be summed to get the overall score. Only Part I was used in this study.

Responsiveness to treatment progress was demonstrated by a significant reduction of

hypochondriacal thought frequency among a group of patients actively engaged in

treatment versus a group awaiting treatment (Barsky & Ahern, 2004). Specific

psychometric data for this measure exclusively with older adults has not been reported.

As this appeared to be the only measure available at the time that assessed

hypochondriacal cognitions, it was chosen for this study.

74

2.1.2.2 Secondary Outcome Measures

Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986). The

ASI is a 16-item measure assessing concern regarding anxiety-related bodily sensations

(Reiss et al., 1986). Each item of the scale is responded to on a 5-point Likert scale that

ranges from 'very little' to 'very much'. The scale has good test-retest reliability. A

reliability of 0.75 was found when assessed over a 2-week interval (Reiss et al., 1986),

0.65 over a 5-week interval (Schmidt, Lerew, & Jackson, 1997), and 0.71 over a 3-year

interval (Maller & Reiss, 1992). The internal consistency of the scale is good and has

ranged from 0.82 to 0.91 (Peterson & Heilbronner, 1987; Schmidt & Joiner, 2002;

Taylor, Koch, & Crockett, 1991; Telch, Shermis, & Lucas, 1989). Within a sample of

community dwelling older adults, the internal consistency of the ASI was found to be

0.92 (Bravo & Silverman, 2001). Research has confirmed the criterion, convergent, and

discriminant validities of the scale (Reiss et al., 1986). Factor analytic research of the

ASI has led to a diversity of findings concerning its factor structure (e.g., Peterson &

Heilbronner, 1987; Schmidt & Joiner, 2002; Telch et al., 1989). However, at this time,

the consensus appears to be that the structure of the ASI is hierarchical with one higher-

order general factor and three lower-order factors assessing physical, mental, and social

concerns (Zinbarg et al., 1997; Zinbarg, Brown, Barlow, & Rapee, 2001). There is some

evidence to suggest that the physical subscale is most strongly associated with heightened

fear during physiological challenges (e.g., hyperventilation; Zinbarg et al., 2001) and

hypervigilance for bodily sensations (Zvolensky & Forsyth, 2002), whereas the mental

75


Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986). The

ASI is a 16-item measure assessing concern regarding anxiety-related bodily sensations

(Reiss et al., 1986). Each item of the scale is responded to on a 5-point Likert scale that

ranges from 'very little' to 'very much'. The scale has good test-retest reliability. A

reliability of 0.75 was found when assessed over a 2-week interval (Reiss et al., 1986),

0.65 over a 5-week interval (Schmidt, Lerew, & Jackson, 1997), and 0.71 over a 3-year

interval (Mailer & Reiss, 1992). The internal consistency of the scale is good and has

ranged from 0.82 to 0.91 (Peterson & Heilbronner, 1987; Schmidt & Joiner, 2002;

Taylor, Koch, & Crockett, 1991; Telch, Shermis, & Lucas, 1989). Within a sample of

community dwelling older adults, the internal consistency of the ASI was found to be

0.92 (Bravo & Silverman, 2001). Research has confirmed the criterion, convergent, and

discriminant validities of the scale (Reiss et al., 1986). Factor analytic research of the

ASI has led to a diversity of findings concerning its factor structure (e.g., Peterson &

Heilbronner, 1987; Schmidt & Joiner, 2002; Telch et al., 1989). However, at this time,

the consensus appears to be that the structure of the ASI is hierarchical with one higher-

order general factor and three lower-order factors assessing physical, mental, and social

concerns (Zinbarg et al., 1997; Zinbarg, Brown, Barlow, & Rapee, 2001). There is some

evidence to suggest that the physical subscale is most strongly associated with heightened

fear during physiological challenges (e.g., hyperventilation; Zinbarg et al., 2001) and

hypervigilance for bodily sensations (Zvolensky & Forsyth, 2002), whereas the mental

75

subscale is most strongly associated with depression (Zinbarg et al., 2001) and emotional

avoidance (Zvolensky & Forsyth, 2002).

A CFA was used to test the adequacy of the model proposed by Zinbarg et al.

(1997) to a sample of 322 community dwelling older adults aged 65 to 97 (Mohlman &

Zinbarg, 2000). The results of the CFA indicated that a bifactor model with a higher

order factor (i.e., anxiety sensitivity) and three first-order factors (Physical Concerns,

Mental Incapacitation Concerns, and Social Concerns) corresponding to Zinbarg et al.'s

(1997) model provided the best fit.

State-Trait Anxiety Inventory (STAI-Form Y; Spielberger, Gorsuch, Lushene,

Montouri, & Platsek, 1983). The STAI was designed to assess both a stable propensity to

experience anxiety in stressful situations and tendencies to perceive stressful situations as

anxiety-provoking (Spielberger, 1983). The portions of the STAI that measure trait and

state anxiety consist of 20 items each (Spielberger, 1983). In the section assessing state

anxiety, respondents indicate on a 4-point rating scale how they feel at this moment.

Response choices include 'not at all,' somewhat,"moderately so,' very much so.' For

each trait anxiety item, respondents indicate on a 4-point rating scale how they generally

feel. Response choices include: 'almost never,' sometimes,"often,' and 'almost

always.' The individual items on each scale can be summed to get the anxiety score.

Scores range from 20-80 on the STAI and higher scores indicate greater anxiety. The

STAI has been found to have good internal consistency (alpha found to range from 0.86

to 0.95), and discriminant and concurrent validity (Spielberger, 1983). The trait scale

76

subscale is most strongly associated with depression (Zinbarg et al., 2001) and emotional

avoidance (Zvolensky & Forsyth, 2002).

A CFA was used to test the adequacy of the model proposed by Zinbarg et al.

(1997) to a sample of 322 community dwelling older adults aged 65 to 97 (Mohlman &

Zinbarg, 2000). The results of the CFA indicated that a bifactor model with a higher

order factor (i.e., anxiety sensitivity) and three first-order factors (Physical Concerns,

Mental Incapacitation Concerns, and Social Concerns) corresponding to Zinbarg et al.'s

(1997) model provided the best fit.

State-Trait Anxiety Inventory (STAI-Form Y; Spielberger, Gorsuch, Lushene,

Montouri, & Platsek, 1983). The STAI was designed to assess both a stable propensity to

experience anxiety in stressful situations and tendencies to perceive stressful situations as

anxiety-provoking (Spielberger, 1983). The portions of the STAI that measure trait and

state anxiety consist of 20 items each (Spielberger, 1983). In the section assessing state

anxiety, respondents indicate on a 4-point rating scale how they feel at this moment.

Response choices include 'not at all,' 'somewhat,' 'moderately so,' 'very much so.' For

each trait anxiety item, respondents indicate on a 4-point rating scale how they generally

feel. Response choices include: 'almost never,' 'sometimes,' 'often,' and 'almost

always.' The individual items on each scale can be summed to get the anxiety score.

Scores range from 20-80 on the STAI and higher scores indicate greater anxiety. The

STAI has been found to have good internal consistency (alpha found to range from 0.86

to 0.95), and discriminant and concurrent validity (Spielberger, 1983). The trait scale

76

further has been shown to have good test-retest reliability (range of 0.73 to 0.86;

Spielberger, 1983).

Among two older adult community subsamples, one with GAD and the other with

no anxiety disorder, internal consistency reliability for the STAI ranged from 0.79-0.94

(Stanley, Beck & Zebb, 1996). The STAI State and Trait scales have demonstrated good

discriminant validity (Dennis, Boddington, & Funnell, 2007). The STAI has been found

to differentiate between older adults with a current anxiety disorder and controls with no

diagnosable psychiatric disorders (Kabacoff, Segal, Hersen, & Van Hesselt, 1997; Kvaal,

Ulstein, Nordhus, & Engedal, 2005). Kvaal et al. (2005) found that a cut-off point of

54/55 on the total STAI state mean sum score discriminated best between those with a

mental disorder and those without. Comprehensive normative data for older adults has

yet to be established, although means and standard deviations are available from the

original authors in an age band spanning 50-69.

Geriatric Depression Scale (GDS; Brink, Yesavage, Lum, Heirsema, Adey, &

Rose, 1982; Yesavage et al., 1983). The GDS is a brief self-report depression scale that

has been specifically designed to assess depression in older people. It consists of 30

items, has a yes-no format, and assesses affective and behavioural symptoms of

depression. Scores on the GDS range from 0-30 and can be categorized into three

groups: (1) 0-9 is normal, (2) 10-19 is mild depression, and (3) 20-30 is severe

depression. One advantage of the GDS over other screening instruments is that it focuses

on psychological aspects of depression by not emphasising somatic items (Tuokko &

Hadjistavropoulos, 1998). The scale can also be read to the participant as the yes-no

77

further has been shown to have good test-retest reliability (range of 0.73 to 0.86;

Spielberger, 1983).

Among two older adult community subsamples, one with GAD and the other with

no anxiety disorder, internal consistency reliability for the STAI ranged from 0.79-0.94

(Stanley, Beck & Zebb, 1996). The STAI State and Trait scales have demonstrated good

discriminant validity (Dennis, Boddington, & Funnell, 2007). The STAI has been found

to differentiate between older adults with a current anxiety disorder and controls with no

diagnosable psychiatric disorders (Kabacoff, Segal, Hersen, & Van Hesselt, 1997; Kvaal,

Ulstein, Nordhus, & Engedal, 2005). Kvaal et al. (2005) found that a cut-off point of

54/55 on the total STAI state mean sum score discriminated best between those with a

mental disorder and those without. Comprehensive normative data for older adults has

yet to be established, although means and standard deviations are available from the

original authors in an age band spanning 50-69.

Geriatric Depression Scale (GDS; Brink, Yesavage, Lum, Heirsema, Adey, &

Rose, 1982; Yesavage et al., 1983). The GDS is a brief self-report depression scale that

has been specifically designed to assess depression in older people. It consists of 30

items, has a yes-no format, and assesses affective and behavioural symptoms of

depression. Scores on the GDS range from 0-30 and can be categorized into three

groups: (1) 0-9 is normal, (2) 10-19 is mild depression, and (3) 20-30 is severe

depression. One advantage of the GDS over other screening instruments is that it focuses

on psychological aspects of depression by not emphasising somatic items (Tuokko &

Hadjistavropoulos, 1998). The scale can also be read to the participant as the yes-no

77

format makes it agreeable to such administration when the participant has problems that

could interfere with reading. The GDS has well-established internal consistency, with

high Cronbach's alpha reliabilities reported ranging from .87 to .94 (Adams, 2001;

Yesavage et al., 1983), and established reliability among independent community

residents, those receiving medical or psychiatric treatments in outpatient and inpatient

settings, as well as institutionalized older adults (Yesavage et al., 1983).

Geriatric Pain Measure (GPM; Ferrell, Stein, & Beck, 2000). The GPM is a

multidimensional pain measure developed for older persons undergoing comprehensive

geriatric assessment. It examines the impact that pain has on function, mood,

engagement in activities, and quality of life. The GPM consists of 24 items that can be

either interview-administered or self-administered and takes approximately five minutes

to complete. Twenty-two items are scored dichotomously and two items scored

categorically on a 0-10 scale. The total score is obtained by summing the "yes"

responses to the dichotomous items with the numerical responses to the categorical items

to give the total score (range = 0 to 42). Factor analysis revealed five clusters of

components: pain intensity, disengagement, pain with ambulation, pain with strenuous

activities, and pain with other activities. Satisfactory internal consistency (alpha = .94;

Brink et al., 1982) and good test-retest reliability (r = .85; Koenig Meador, Cohen, &

Blazer, 1988) have been demonstrated.

Short Form-12 Health Survey (SF-12; Ware, Kosinski, & Keller, 1996). The SF-

12 is a self-administered questionnaire consisting of 12 items derived from the SF-36

Health Survey. The SF-12 measures eight domains of health, including physical

78

format makes it agreeable to such administration when the participant has problems that

could interfere with reading. The GDS has well-established internal consistency, with

high Cronbach's alpha reliabilities reported ranging from .87 to .94 (Adams, 2001;

Yesavage et al., 1983), and established reliability among independent community

residents, those receiving medical or psychiatric treatments in outpatient and inpatient

settings, as well as institutionalized older adults (Yesavage et al., 1983).

Geriatric Pain Measure (GPM; Ferrell, Stein, & Beck, 2000). The GPM is a

multidimensional pain measure developed for older persons undergoing comprehensive

geriatric assessment. It examines the impact that pain has on function, mood,

engagement in activities, and quality of life. The GPM consists of 24 items that can be

either interview-administered or self-administered and takes approximately five minutes

to complete. Twenty-two items are scored dichotomously and two items scored

categorically on a 0-10 scale. The total score is obtained by summing the "yes"

responses to the dichotomous items with the numerical responses to the categorical items

to give the total score (range = 0 to 42). Factor analysis revealed five clusters of

components: pain intensity, disengagement, pain with ambulation, pain with strenuous

activities, and pain with other activities. Satisfactory internal consistency (alpha = .94;

Brink et al., 1982) and good test-retest reliability (r = .85; Koenig Meador, Cohen, &

Blazer, 1988) have been demonstrated.

Short Form-12 Health Survey (SF-12; Ware, Kosinski, & Keller, 1996). The SF-

12 is a self-administered questionnaire consisting of 12 items derived from the SF-36

Health Survey. The SF-12 measures eight domains of health, including physical

78

functioning (ability to perform daily activities as well as strenuous activities), role-

physical (limitations of one's physical health on work or other activities), bodily pain

(amount of pain felt and its interference on normal activities), general health (perceived

general health), vitality (tiredness and energy), social functioning (whether physical and

emotional health affects one's social activities), role-emotional (extent to which work or

other activities are limited due to emotional problems), and mental health (emotional

well-being) (Ware, Kosinski, Turner-Bowker, & Gandek, 2002). For ease of use, the

eight domain scales have been combined into two larger component scales including (1)

physical component summary (PCS) (physical functioning, role-physical, bodily pain,

general health), and (2) mental component summary (MCS) (vitality, social functioning,

role-emotional, mental health) (Ware et al., 2002). The SF-36 and SF-12 component

scales are highly correlated, r = .95 for PCS and r = .97 for MCS (Ware et al., 1996).

Test-retest reliability (two weeks) of the PCS-12 ranges from 0.86 to 0.89, and 0.76 to

0.77 for the MCS-12 (Ware et al., 1996). For the eight domain scale scores, test-retest

reliability was 0.63 to 0.91 (Ware et al., 1996). Relative validity coefficients for the PCS-

12 ranged from 0.43 to 0.78, and from 0.93 to 0.98 for the MCS-12 (Ware et al., 2002).

2.1.2.3 Measures of the Therapeutic Relationship and Motivation for Psychotherapy

The Working Alliance Inventory — Client Form (WAI; Horvath & Greenberg,

1989). The WAI is a 36 item self-report scale designed to assess the therapeutic

relationship. The WAI comprises three scales, including the Bond scale, which measures

the therapeutic bond (e.g., attachment, mutual liking, trust), the Tasks scale, which

measures agreement on joint tasks (e.g., techniques and strategies of treatment), and the

79

functioning (ability to perform daily activities as well as strenuous activities), role-

physical (limitations of one's physical health on work or other activities), bodily pain

(amount of pain felt and its interference on normal activities), general health (perceived

general health), vitality (tiredness and energy), social functioning (whether physical and

emotional health affects one's social activities), role-emotional (extent to which work or

other activities are limited due to emotional problems), and mental health (emotional

well-being) (Ware, Kosinski, Turner-Bowker, & Gandek, 2002). For ease of use, the

eight domain scales have been combined into two larger component scales including (1)

physical component summary (PCS) (physical functioning, role-physical, bodily pain,

general health), and (2) mental component summary (MCS) (vitality, social functioning,

role-emotional, mental health) (Ware et al., 2002). The SF-36 and SF-12 component

scales are highly correlated, r = .95 for PCS and r = .97 for MCS (Ware et al., 1996).

Test-retest reliability (two weeks) of the PCS-12 ranges from 0.86 to 0.89, and 0.76 to

0.77 for the MCS-12 (Ware et al., 1996). For the eight domain scale scores, test-retest

reliability was 0.63 to 0.91 (Ware et al., 1996). Relative validity coefficients for the PCS-

12 ranged from 0.43 to 0.78, and from 0.93 to 0.98 for the MCS-12 (Ware et al., 2002).

2.1.2.3 Measures of the Therapeutic Relationship and Motivation for Psychotherapy

The Working Alliance Inventory - Client Form (WAI; Horvath & Greenberg,

1989). The WAI is a 36 item self-report scale designed to assess the therapeutic

relationship. The WAI comprises three scales, including the Bond scale, which measures

the therapeutic bond (e.g., attachment, mutual liking, trust), the Tasks scale, which

measures agreement on joint tasks (e.g., techniques and strategies of treatment), and the

79

Goals scale, which measures agreement about treatment goals (e.g., areas targeted for

change). Participants respond to each item on a 7-point Likert scale that ranges from

`does not correspond at all' to 'corresponds exactly." The reliability estimate for the

client form of the WAI has been reported at Cronbach's a = 0.98, and test-retest reliability

was r = 0.83 across a 2-week period (Tracey & Kokotovic, 1989). For the purpose of this

study, the WAI was administered on the first, third, and last sessions. The WAI was

chosen because it is based on Bordin's transtheoretical model (Bordin, 1979) of the

therapeutic alliance. Specific psychometric data for this measure exclusively with older

adults has not been reported.

Nijmegen Motivation List-2 (NML-2; Keijsers et al., 1999) is a 24 item instrument

designed to measure patient motivation for CBT. The participant rates the extent to

which each statement applied to him or her on a 6-point scale, ranging from 'not at all

applicable' to 'very applicable.' A factor analysis by Keijsers et al. (1999) of the NML-2

resulted in three factors: (1) Preparedness, which measures the patient's preparedness to

actively invest in treatment and to make sacrifices; (2) Distress, which measures pressure

by others and level of distress; and (3) Doubt, which measures doubt about the

investment in treatment, the treatment itself, and the possibility of gaining from it.

Internal consistencies for the factors were reasonable and the Cronbach's alphas ranged

from .71 to .84 (Keijsers et al., 1999). Test-retest reliabilities for the three subscales

ranged from .69 to .78. The NML-2 predicted decreases in GAD symptoms at 6- and 24-

month follow-ups in a sample of 52 adults with a principal diagnosis of GAD received

CBT (Dugas et al., 2003). This measure was chosen because it was specifically designed

80

Goals scale, which measures agreement about treatment goals (e.g., areas targeted for

change). Participants respond to each item on a 7-point Likert scale that ranges from

'does not correspond at all' to 'corresponds exactly." The reliability estimate for the

client form of the WAI has been reported at Cronbach's a = 0.98, and test-retest reliability

was r = 0.83 across a 2-week period (Tracey & Kokotovic, 1989). For the purpose of this

study, the WAI was administered on the first, third, and last sessions. The WAI was

chosen because it is based on Bordin's transtheoretical model (Bordin, 1979) of the

therapeutic alliance. Specific psychometric data for this measure exclusively with older

adults has not been reported.

Nijmegen Motivation List-2 (NML-2; Keijsers et al., 1999) is a 24 item instrument

designed to measure patient motivation for CBT. The participant rates the extent to

which each statement applied to him or her on a 6-point scale, ranging from 'not at all

applicable' to 'very applicable.' A factor analysis by Keijsers et al. (1999) of the NML-2

resulted in three factors: (1) Preparedness, which measures the patient's preparedness to

actively invest in treatment and to make sacrifices; (2) Distress, which measures pressure

by others and level of distress; and (3) Doubt, which measures doubt about the

investment in treatment, the treatment itself, and the possibility of gaining from it.

Internal consistencies for the factors were reasonable and the Cronbach's alphas ranged

from .71 to .84 (Keijsers et al., 1999). Test-retest reliabilities for the three subscales

ranged from .69 to .78. The NML-2 predicted decreases in GAD symptoms at 6- and 24-

month follow-ups in a sample of 52 adults with a principal diagnosis of GAD received

CBT (Dugas et al., 2003). This measure was chosen because it was specifically designed

80

to measure patient motivation for CBT. Specific psychometric data for this measure

exclusively with older adults has not been reported.

2.1.3 Therapy Programs: Standard Cognitive Behavioural Therapy (SCBT) and

Enhanced Cognitive Behavioural Therapy (ECBT)

The SCBT program was designed by Barsky and Ahern (2004) and is consistent

with principles of the CB model of health anxiety. This program was chosen because it

was brief (six sessions) and written in English. Further, permission was granted by Dr.

Barsky for us to use and adapt his program. This program has been found to be effective

for the treatment of hypochondriasis with younger adults (Barsky & Ahern, 2004). The

topics that were covered in both the SCBT and ECBT programs include the following:

(1) education about the nature of health anxiety, (2) improving understanding and ability

to control health anxiety using psychological means (e.g., coping strategies, attention and

distraction techniques), (3) self-monitoring (i.e., keeping track of anxiety and methods

one can use to deal with it), (4) improving the understanding and management of stress,

(5) examining thoughts and beliefs about health anxiety, (6) improving behaviours and

activities that have an impact on health anxiety, (7) improving other emotional states

(e.g., depression) that have an impact on health anxiety, and (8) maintaining

improvements in emotional functioning.

The ECBT program covered the same topics but also included learning and

memory aids and videos designed to make the therapy more effective with older adults

(see Appendix C for outline of videos) following recommendations by Mohlman and

81

to measure patient motivation for CBT. Specific psychometric data for this measure

exclusively with older adults has not been reported.

2.1.3 Therapy Programs: Standard Cognitive Behavioural Therapy (SCBT) and

Enhanced Cognitive Behavioural Therapy (ECBT)

The SCBT program was designed by Barsky and Ahern (2004) and is consistent

with principles of the CB model of health anxiety. This program was chosen because it

was brief (six sessions) and written in English. Further, permission was granted by Dr.

Barsky for us to use and adapt his program. This program has been found to be effective

for the treatment of hypochondriasis with younger adults (Barsky & Ahern, 2004). The

topics that were covered in both the SCBT and ECBT programs include the following:

(1) education about the nature of health anxiety, (2) improving understanding and ability

to control health anxiety using psychological means (e.g., coping strategies, attention and

distraction techniques), (3) self-monitoring (i.e., keeping track of anxiety and methods

one can use to deal with it), (4) improving the understanding and management of stress,

(5) examining thoughts and beliefs about health anxiety, (6) improving behaviours and

activities that have an impact on health anxiety, (7) improving other emotional states

(e.g., depression) that have an impact on health anxiety, and (8) maintaining

improvements in emotional functioning.

The ECBT program covered the same topics but also included learning and

memory aids and videos designed to make the therapy more effective with older adults

(see Appendix C for outline of videos) following recommendations by Mohlman and

81

colleagues (2003). The following learning and memory aids were added to the SCBT

program:

■ Weekly reading assignments meant to reinforce session material (this written

information can be used as a reference throughout the weeks).

■ Graphing exercises in which participants chart numerical mood ratings averaged

over each week (meant to highlight gradual progress, reveal patterns in moods, and

facilitate discussion).

■ Mid-week homework reminder/troubleshooting calls from the therapist for the first

four assignments (meant to alleviate participants' ambivalence about asking for

help and review the procedures and goals of the assignment, decrease social

isolation often common among seniors).

■ A perspective-taking strategy to facilitate evidence generation in cognitive-

restructuring exercises (i.e., each participant was asked to generate a list of three to

five individuals who they believe are good problem solvers and generate evidence

that refutes automatic thoughts from the perspective of each person on the list)

which was meant to reduce automatic thoughts through the enhancement of

generative thinking abilities and broadened perspectives.

■ Short videos with older adults giving personal testimonials about the program

which were used to help socialize the client to treatment and ultimately to enhance

motivation.

82

colleagues (2003). The following learning and memory aids were added to the SCBT

program:

• Weekly reading assignments meant to reinforce session material (this written

information can be used as a reference throughout the weeks).

• Graphing exercises in which participants chart numerical mood ratings averaged

over each week (meant to highlight gradual progress, reveal patterns in moods, and

facilitate discussion).

• Mid-week homework reminder/troubleshooting calls from the therapist for the first

four assignments (meant to alleviate participants' ambivalence about asking for

help and review the procedures and goals of the assignment, decrease social

isolation often common among seniors).

• A perspective-taking strategy to facilitate evidence generation in cognitive-

restructuring exercises (i.e., each participant was asked to generate a list of three to

five individuals who they believe are good problem solvers and generate evidence

that refutes automatic thoughts from the perspective of each person on the list)

which was meant to reduce automatic thoughts through the enhancement of

generative thinking abilities and broadened perspectives.

• Short videos with older adults giving personal testimonials about the program

which were used to help socialize the client to treatment and ultimately to enhance

motivation.

82

2.1.4 Procedure

Ethics approval for this study was obtained from the University of Regina Research

Ethics Board (see Appendix D). All participants were screened first by telephone with

the WI to assess levels of health anxiety. The WI was used to eliminate individuals who

clearly did not have health anxiety and would not benefit from the treatment being

offered. Potential participants were also asked to report their age. It was decided, due to

difficulties with recruitment, that two participants both aged 57 years (one from the

SCBT group and one from the ECBT group) and above would be allowed to participate.

Other researchers who conduct research with older adults often include those above the

age of 55 (e.g., Byers et al., 2010). Those participants with a score of eight or higher on

the WI were then invited to our clinic for completion of the questionnaire package and

semi-structured interview. A member of the research team met with the participants to

fill out the questionnaires at the Psychology Training Clinic at the University of Regina

or at an otherwise convenient location (e.g., participant's home). A consent form was

presented to participants before they began any questionnaires or therapy. Following

this, participants were randomly assigned to SCBT, ECBT, or to the WLC group. The

randomized allocation sequence was computer generated in blocks of 10. Allocation of

participants to the specific group was concealed from the initial assessor until after the

assessment was complete and the participant was deemed to meet eligibility criteria. The

questionnaire package was completed on three different occasions: once when the study

began, once immediately after the study was over, and one final time three months after

the treatment program ended. The questionnaire package consisted of a section assessing

83

2.1.4 Procedure

Ethics approval for this study was obtained from the University of Regina Research

Ethics Board (see Appendix D). All participants were screened first by telephone with

the WI to assess levels of health anxiety. The WI was used to eliminate individuals who

clearly did not have health anxiety and would not benefit from the treatment being

offered. Potential participants were also asked to report their age. It was decided, due to

difficulties with recruitment, that two participants both aged 57 years (one from the

SCBT group and one from the ECBT group) and above would be allowed to participate.

Other researchers who conduct research with older adults often include those above the

age of 55 (e.g., Byers et al., 2010). Those participants with a score of eight or higher on

the WI were then invited to our clinic for completion of the questionnaire package and

semi-structured interview. A member of the research team met with the participants to

fill out the questionnaires at the Psychology Training Clinic at the University of Regina

or at an otherwise convenient location (e.g., participant's home). A consent form was

presented to participants before they began any questionnaires or therapy. Following

this, participants were randomly assigned to SCBT, ECBT, or to the WLC group. The

randomized allocation sequence was computer generated in blocks of 10. Allocation of

participants to the specific group was concealed from the initial assessor until after the

assessment was complete and the participant was deemed to meet eligibility criteria. The

questionnaire package was completed on three different occasions: once when the study

began, once immediately after the study was over, and one final time three months after

the treatment program ended. The questionnaire package consisted of a section assessing

83

demographic and background information (Appendix D), the SHAI, IAS, SSAS, SSI,

HCQ, STAI, ASI, GDS, GPM, and SF-12. The questionnaires assessing health anxiety

were placed first in order in the package given the results of a previous study that

demonstrated that focusing on one's own health can influence ratings of health anxiety

(Lister, Rode, Farmer, & Salkovskis, 2002). At three-month follow-up, the demographic

and background information sections, semi-structured interview, WAI, and NML-2 were

omitted from the questionnaire package. Participants were asked to complete the WAI in

order to provide information on the relationship with their therapist after the first, third

session, and again after the final session. The NML-2 was also completed after the first,

third, and final sessions. Open-ended questions, which have been described above, were

also included at pre-treatment and at post-treatment.

Participants randomly assigned to the two experimental conditions received either

the SCBT or ECBT program immediately after the initial questionnaires were completed.

The participants in these conditions attended the intervention once a week for one hour,

over a six week period. Participants who were randomly assigned to the WLC group

were offered the ECBT health anxiety treatment program no later than six weeks

following their enrolment in the study. Therapy was conducted by the researcher and

three other graduate students in the Clinical Psychology programme at the University of

Regina who were trained in provision of the treatment program. Training of the student

therapists consisted of a review of the treatment manual, review of the treatment videos,

and direction provided by the researcher. Supervision was provided by Heather

Hadjistavropoulos, Ph.D., a registered doctoral psychologist, while doctoral students

84

demographic and background information (Appendix D), the SHAI, IAS, SSAS, SSI,

HCQ, STAI, ASI, GDS, GPM, and SF-12. The questionnaires assessing health anxiety

were placed first in order in the package given the results of a previous study that

demonstrated that focusing on one's own health can influence ratings of health anxiety

(Lister, Rode, Farmer, & Salkovskis, 2002). At three-month follow-up, the demographic

and background information sections, semi-structured interview, WAI, and NML-2 were

omitted from the questionnaire package. Participants were asked to complete the WAI in

order to provide information on the relationship with their therapist after the first, third

session, and again after the final session. The NML-2 was also completed after the first,

third, and final sessions. Open-ended questions, which have been described above, were

also included at pre-treatment and at post-treatment.

Participants randomly assigned to the two experimental conditions received either

the SCBT or ECBT program immediately after the initial questionnaires were completed.

The participants in these conditions attended the intervention once a week for one hour,

over a six week period. Participants who were randomly assigned to the WLC group

were offered the ECBT health anxiety treatment program no later than six weeks

following their enrolment in the study. Therapy was conducted by the researcher and

three other graduate students in the Clinical Psychology programme at the University of

Regina who were trained in provision of the treatment program. Training of the student

therapists consisted of a review of the treatment manual, review of the treatment videos,

and direction provided by the researcher. Supervision was provided by Heather

Hadjistavropoulos, Ph.D., a registered doctoral psychologist, while doctoral students

84

conducted the six week intervention. Sessions were offered at Psychology Training

Clinic at the University of Regina. See Figure 3 for a profile of the randomized control

trial. The procedure described above follows the Consolidated Standards of Reporting

Trials (CONSORT) as outlined by Schulz, Altman, and Moher (2010).

2.1.5 Design and Analyses

2.1.5.1 Analyses

In order to test the hypothesis that participants receiving SCBT and ECBT, but

not those in the WLC, would evidence improvements in health anxiety, frequency of


bodily sensations as being distressing, state anxiety, depression, pain, and health-related

quality of life from pre-treatment to post-treatment, a series of mixed factor analyses of

covariance (ANCOVAs) were used to compare the treatment group and control group

scores on the dependent variables (i.e., WI, SHAI, IAS, SSI, SSAS, HCQ, ASI, STAI-S,

STAI-T, GDS, GPM, SF-12-PCS, SF-12-MCS) at baseline and post-treatment, with the

pre-treatment value of the measure of interest in the analysis set as the covariate. This

analytic method has more power than analysis of variance when treatment assignment is

randomized (van Breukelen, 2006; Vickers, 2004), as was the case for this study.

To test the hypotheses (1) that participants treated with ECBT would demonstrate

the greatest overall improvement (as assessed by the dependent measures) at follow-up in

each of the areas indicated in the first hypothesis, and (2) that participants treated with

both SCBT and ECBT would maintain improvements at three months following the

85

conducted the six week intervention. Sessions were offered at Psychology Training

Clinic at the University of Regina. See Figure 3 for a profile of the randomized control

trial. The procedure described above follows the Consolidated Standards of Reporting

Trials (CONSORT) as outlined by Schulz, Altman, and Moher (2010).

2.1.5 Design and Analyses

2.1.5.1 Analyses

In order to test the hypothesis that participants receiving SCBT and ECBT, but

not those in the WLC, would evidence improvements in health anxiety, frequency of


bodily sensations as being distressing, state anxiety, depression, pain, and health-related

quality of life from pre-treatment to post-treatment, a series of mixed factor analyses of

covariance (ANCOVAs) were used to compare the treatment group and control group

scores on the dependent variables (i.e., WI, SHAI, IAS, SSI, SSAS, HCQ, ASI, STAI-S,

STAI-T, GDS, GPM, SF-12-PCS, SF-12-MCS) at baseline and post-treatment, with the

pre-treatment value of the measure of interest in the analysis set as the covariate. This

analytic method has more power than analysis of variance when treatment assignment is

randomized (van Breukelen, 2006; Vickers, 2004), as was the case for this study.

To test the hypotheses (1) that participants treated with ECBT would demonstrate

the greatest overall improvement (as assessed by the dependent measures) at follow-up in

each of the areas indicated in the first hypothesis, and (2) that participants treated with

both SCBT and ECBT would maintain improvements at three months following the

85

110 individuals assessed for eligibility

v57 individuals randomly

assigned

53 individuals were excluded • 37 did not meet inclusion

criteria • 19 declined to participate

SCBT - 21 individuals completed questionnaires and allocated

19 individuals in analyses at post-treatment • 2 individuals

dropped out

19 individuals in analyses at follow-up

ECBT - 18 individuals completed questionnaires and allocated

17 individuals in analyses post-treatment • 1 individual

dropped out


• WLC - 18 individuals completed questionnaires and allocated

•18 individuals completed at post-treatment

Figure 3. Flow of participants through the treatments.



86

SCBT-21 individuals completed questionnaires and allocated

19 individuals in analyses at post-treatment • 2 individuals

dropped out

110 individuals assessed for eligibility

57 individuals randomly assigned

ECBT-18 individuals completed questionnaires and allocated

17 individuals in analyses post-treatment • 1 individual

dropped out

1 '


i '


53 individuals were excluded • 37 did not meet inclusion

criteria • 19 declined to participate

WLC-18 individuals completed questionnaires and allocated

18 individuals completed at post-treatment

Figure 3. Flow of participants through the treatments.



86

conclusion of treatment, a series of mixed model ANCOVAs were used to compare the

SCBT and ECBT on each of the dependent variables. In order to test the hypotheses that

participants treated with ECBT would demonstrate a higher level of therapeutic alliance

and motivation for treatment at three and six weeks than those receiving SCBT, a series

of mixed model ANCOVAs were used to compare the SCBT and ECBT on each of the

dependent variables.

An intent-to-treat (ITT) analysis was conducted in order to evaluate pre- to post-

treatment effects for all participants who intended to participate, regardless of whether he

or she dropped out or not. Thus, in addition to the participants who completed treatment,

all participants who were randomized to either the SCBT or ECBT conditions and

completed all pre-treatment questionnaires and at least one treatment session (two from

the SCBT group and one from the ECBT group) were included in the ITT analysis.

2.1.5.2 Preparation of the Data for Analysis

The alpha level for the mixed factor ANCOVAs tests was set at .05. Results of

evaluation of assumptions of normality and homogeneity of variance-covariance matrixes

were satisfactory. The assumption of sphericity for all repeated measures analyses was

met or was corrected for using the Greenhouse-Geisser correction provided by SPSS.

Assessment for outliers was conducted by examining the z-scores for each dependent and

independent variable. Based on the recommended criteria that z-scores greater than 3.29

should be considered outliers (Tabachnick & Fidell, 2001), there were no outlying data

points identified. Next, the pattern of missing data was examined and mean substitution

was used to replace the missing value in those instances where there was only very

87

conclusion of treatment, a series of mixed model ANCOVAs were used to compare the

SCBT and ECBT on each of the dependent variables. In order to test the hypotheses that


and motivation for treatment at three and six weeks than those receiving SCBT, a series

of mixed model ANCOVAs were used to compare the SCBT and ECBT on each of the

dependent variables.

An intent-to-treat (ITT) analysis was conducted in order to evaluate pre- to post-

treatment effects for all participants who intended to participate, regardless of whether he

or she dropped out or not. Thus, in addition to the participants who completed treatment,

all participants who were randomized to either the SCBT or ECBT conditions and

completed all pre-treatment questionnaires and at least one treatment session (two from

the SCBT group and one from the ECBT group) were included in the ITT analysis.

2.1.5.2 Preparation of the Data for Analysis

The alpha level for the mixed factor ANCOVAs tests was set at .05. Results of

evaluation of assumptions of normality and homogeneity of variance-covariance matrixes

were satisfactory. The assumption of sphericity for all repeated measures analyses was

met or was corrected for using the Greenhouse-Geisser correction provided by SPSS.

Assessment for outliers was conducted by examining the z-scores for each dependent and

independent variable. Based on the recommended criteria that z-scores greater than 3.29

should be considered outliers (Tabachnick & Fidell, 2001), there were no outlying data

points identified. Next, the pattern of missing data was examined and mean substitution

was used to replace the missing value in those instances where there was only very

87

minimal missing data (e.g., if a participant did not complete one whole questionnaire or

left blank more than two questions in a row data was not replaced). In total, less than one

percent of the data were replaced. All analyses were conducted on an ITT basis. The

analyses included all subjects with a pre-treatment measurement, regardless of the

duration of their treatment. For the three drop-outs, pre-treatment data were carried

forward to serve as post-treatment scores (last-observation carried-forward (LOCF)

technique) (Greeven, van Balkom, van der Leeden, Merkelbach, van den Heuvel, &

Spinhoven, 2007; Sorensen et al., in press).

2.1.5.3 Qualitative Data Analysis

The current data was comprised of participants' responses to the open-ended

questions completed at pre-treatment and post-treatment by participants in both the SCBT

and ECBT groups. The questions described in the Method section were attached at the

end of the questionnaire packages and participants were asked to respond to questions in

writing. All the responses were read and then entered into a Microsoft Word document.

After inputting all the responses, the following coding process took place.

Coding. Analysis from a grounded theory perspective is a systematic process that

occurs in various stages (Strauss & Corbin, 1998). Data were analyzed using a three-

stage coding process which included open, axial, and selective coding procedures

(Strauss & Corbin, 1998).

Open coding. For the open coding stage, raw data were named and categorized

after being broken down into discrete parts, examined closely, compared for similarities

and differences, interpreted, and reconstructed to establish conceptual labels or

88

minimal missing data (e.g., if a participant did not complete one whole questionnaire or

left blank more than two questions in a row data was not replaced). In total, less than one

percent of the data were replaced. All analyses were conducted on an ITT basis. The

analyses included all subjects with a pre-treatment measurement, regardless of the

duration of their treatment. For the three drop-outs, pre-treatment data were carried

forward to serve as post-treatment scores (last-observation carried-forward (LOCF)

technique) (Greeven, van Balkom, van der Leeden, Merkelbach, van den Heuvel, &

Spinhoven, 2007; Sorensen et al., in press).

2.1.5.3 Qualitative Data Analysis

The current data was comprised of participants' responses to the open-ended

questions completed at pre-treatment and post-treatment by participants in both the SCBT

and ECBT groups. The questions described in the Method section were attached at the

end of the questionnaire packages and participants were asked to respond to questions in

writing. All the responses were read and then entered into a Microsoft Word document.

After inputting all the responses, the following coding process took place.

Coding. Analysis from a grounded theory perspective is a systematic process that

occurs in various stages (Strauss & Corbin, 1998). Data were analyzed using a three-

stage coding process which included open, axial, and selective coding procedures

(Strauss & Corbin, 1998).

Open coding. For the open coding stage, raw data were named and categorized

after being broken down into discrete parts, examined closely, compared for similarities

and differences, interpreted, and reconstructed to establish conceptual labels or

88

interpretative schemes (Strauss & Corbin, 1998). An initial list of open codes was

developed for the pre-treatment responses and for the post-treatment responses through

examination of participants' responses to the open-ended questions.

Axial coding. In the axial coding stage, categories pertaining to the research

questions were derived from the emerging concepts (Strauss & Corbin, 1998).

Specifically, ideas that were conceptually related were grouped together. At this stage of

the coding process, open codes were collapsed to develop categories. Then, direct quotes

from the responses that were conceptually related were cut from original document and

pasted together to emphasize a particular category. Higher order concepts within each

category began to emerge and they were compared to establish abstract concepts (Strauss

& Corbin, 1998).

Selective coding. To facilitate the development of models that describe older

adults' experiences of health anxiety and older adults' experiences of the psychological

treatment of health anxiety, selective coding procedures were subsequently employed. In

the selective coding stage, comparisons and links were made across categories (Strauss &

Corbin, 1998). The core tasks in this stage were to identify the core themes and sub-

themes to form a model of older adults' development of health anxiety and older adults'

experiences in the psychological treatment of health anxiety. The diagrammatic

representations of the emergent models based on the themes derived from the original

data provide a visual description (Strauss & Corbin, 1998). These both appear in the

Results section. To represent the emergent themes of the final analysis and the

integrated perceptions and experiences of the older adults, verbatim quotes were selected

89

interpretative schemes (Strauss & Corbin, 1998). An initial list of open codes was

developed for the pre-treatment responses and for the post-treatment responses through

examination of participants' responses to the open-ended questions.

Axial coding. In the axial coding stage, categories pertaining to the research

questions were derived from the emerging concepts (Strauss & Corbin, 1998).

Specifically, ideas that were conceptually related were grouped together. At this stage of

the coding process, open codes were collapsed to develop categories. Then, direct quotes

from the responses that were conceptually related were cut from original document and

pasted together to emphasize a particular category. Higher order concepts within each

category began to emerge and they were compared to establish abstract concepts (Strauss

& Corbin, 1998).

Selective coding. To facilitate the development of models that describe older

adults' experiences of health anxiety and older adults' experiences of the psychological

treatment of health anxiety, selective coding procedures were subsequently employed. In

the selective coding stage, comparisons and links were made across categories (Strauss &

Corbin, 1998). The core tasks in this stage were to identify the core themes and sub-

themes to form a model of older adults' development of health anxiety and older adults'

experiences in the psychological treatment of health anxiety. The diagrammatic

representations of the emergent models based on the themes derived from the original

data provide a visual description (Strauss & Corbin, 1998). These both appear in the

Results section. To represent the emergent themes of the final analysis and the

integrated perceptions and experiences of the older adults, verbatim quotes were selected

89

from the responses to the open-ended questions. Those quotes are also presented in the

Results section.

To ensure reliability of the coding of the themes and sub-themes, a second

researcher examined the raw data, coding, themes, and sub-themes, engaging in the same

process described above. Any differences in opinion were resolved via discussion.

2.2 Study 2

2.2.1 Participants and Procedure

In order to recruit control participants for comparison with the older adult sample

recruited in Study 1, the research was advertised on online classified websites across

Canada (e.g., www.craigslist.com, www.usedregina.com). Participants were informed of

the nature of the study and invited to take part in the 30 minute study by connecting to the

survey via a link posted on the advertisement (Appendix F). The main page of the survey

described the nature and purpose of the study (Appendix G), and required the participants

to indicate whether they consented to participate before moving forward with the survey.

Participants completed a battery of self-report questionnaires including the WI, SHAI,

IAS, SSI, SSAS, HCQ, ASI, and STAI (all measures are described above). Once all

questionnaires were completed and submitted, participants had the option of entering

their name in a draw to win one of three $20 Chapters gift certificates.

A total of 296 potential control participants responded to recruitment

advertisements. Of these individuals, 220 fully completed all the questionnaires.

Participants from the control group were then matched to the older adult participants by

sex and WI score (a score of greater than or equal to 8). Sex and WI score matches were

90

from the responses to the open-ended questions. Those quotes are also presented in the

Results section.

To ensure reliability of the coding of the themes and sub-themes, a second

researcher examined the raw data, coding, themes, and sub-themes, engaging in the same

process described above. Any differences in opinion were resolved via discussion.

2.2 Study 2

2.2.1 Participants and Procedure

In order to recruit control participants for comparison with the older adult sample

recruited in Study 1, the research was advertised on online classified websites across

Canada (e.g., www.craigslist.com, www.usedregina.com). Participants were informed of

the nature of the study and invited to take part in the 30 minute study by connecting to the

survey via a link posted on the advertisement (Appendix F). The main page of the survey

described the nature and purpose of the study (Appendix G), and required the participants

to indicate whether they consented to participate before moving forward with the survey.

Participants completed a battery of self-report questionnaires including the WI, SHAI,

IAS, SSI, SSAS, HCQ, ASI, and STAI (all measures are described above). Once all

questionnaires were completed and submitted, participants had the option of entering

their name in a draw to win one of three $20 Chapters gift certificates.

A total of 296 potential control participants responded to recruitment

advertisements. Of these individuals, 220 fully completed all the questionnaires.

Participants from the control group were then matched to the older adult participants by

sex and WI score (a score of greater than or equal to 8). Sex and WI score matches were

90

http://www.craigslist.com

http://www.usedregina.com

made for 57 pairs of the older adult sample (n = 57) and control sample (n = 57)

participants. The mean age of participants in the control group was 33.05 (SD = 9.50)

years of age, compared to 68.70 (SD = 6.92) years of age in the older adult group. Both

groups were comprised of 44 (77.2%) females (there was no significant difference, X2 (1,

114) = .000, p = 1.00. There was no significant difference found between groups with

regard to relationship status, X2 (1, 114) = .04,p = .85. In both groups, the majority of

participants were not married (older adult group — N = 32, 56.1%; control group = N = 31,

54.4%). There was a statistically significant difference in participants' highest level of

education, X2 (1, 114) = 13.37, p = .0001, with 89.5% of control participants (n = 51)

having more than a high school education, compared to 59.6% (n = 34) of the older adult

participants having more than a high school education. Control participants also had a

significantly lower average number of health conditions than the older adult group, t(112)

= 7.79,p = .0001 (older adult group: M= 2.30, SD = 1.46; control group: M .54, SD =

.87) (see Table 4 for demographic information). The most common conditions cited for

the older adults were arthritis (56.1%), high blood pressure (43.9%), and osteoporosis

(31.7%). For the younger adults, the most common conditions cited were arthritis

(14.0%), vision problems (12.3%), and hearing problems (8.8%) (see Tables 4 and 5).

2.2.2 Preparation of the Data for Analysis

Prior to conducting the analyses, the data set was cleaned and screened for

accuracy. Assessment for outliers was conducted by examining the z-scores for each

dependent and independent variable. Based on the recommended criteria that z-scores

greater than 3.29 should be considered outliers (Tabachnick & Fidell, 2001), there were

91

made for 57 pairs of the older adult sample (n = 57) and control sample (n = 57)

participants. The mean age of participants in the control group was 33.05 (SD = 9.50)

years of age, compared to 68.70 (SD = 6.92) years of age in the older adult group. Both

groups were comprised of 44 (77.2%) females (there was no significant difference, x2 (1,

114) = .000, p = 1.00. There was no significant difference found between groups with

regard to relationship status, x2 (1, 114) = .04,p = .85. In both groups, the majority of

participants were not married (older adult group - iV = 32, 56.1 %; control group = TV = 31,

54.4%»). There was a statistically significant difference in participants' highest level of

education, x2 (1, 114) = 13.37, p = .0001, with 89.5% of control participants (n = 51)

having more than a high school education, compared to 59.6% (n = 34) of the older adult

participants having more than a high school education. Control participants also had a

significantly lower average number of health conditions than the older adult group, ^(112)

= 7.79,p = .0001 (older adult group: M= 2.30, SD = 1.46; control group: M= .54, SD =

.87) (see Table 4 for demographic information). The most common conditions cited for

the older adults were arthritis (56.1%), high blood pressure (43.9%), and osteoporosis

(31.7%). For the younger adults, the most common conditions cited were arthritis

(14.0%)), vision problems (12.3%), and hearing problems (8.8%) (see Tables 4 and 5).

2.2.2 Preparation of the Data for Analysis

Prior to conducting the analyses, the data set was cleaned and screened for

accuracy. Assessment for outliers was conducted by examining the z-scores for each

dependent and independent variable. Based on the recommended criteria that z-scores

greater than 3.29 should be considered outliers (Tabachnick & Fidell, 2001), there were

91

Table 4

Demographic Information and Scale Scores for Matched Participants

Demographic Characteristic Older Adult

Group

Matched

Control Group

M (SD) M (SD) T

Age 68.70 6.92 33.05 (9.50) 22.90***

Number of Health Conditions 2.30 1.46 .54 (0.87) 7.79***

N % N % x2 Sex

Female 44 77.2 44 77.2 .000

Male 13 22.8 13 22.8

Marital Status

Married/Common-Law 25 43.9 26 45.6 .04

Not Married 32 56.1 31 54.4

Education

< High School 23 40.4 6 10.5 13.37***

> = High School 34 59.6 51 89.5

Notes: *p < .05, **p < .01, ***p < .001

92

Table 4

Demographic Information and Scale Scores for Matched Participants

Demographic Characteristic

Age

Number of Health Conditions

Sex

Female

Male

Older Adult

Group

M

68.70

2.30

N

44

13

(SD)

6.92

1.46

%

77.2

22.8

Matched

Control Group

M

33.05

.54

N

44

13

(SD)

(9.50)

(0.87)

%

77.2

22.8

T

22.90***

7 79***

7?

.000

Marital Status

Married/Common-Law 25 43.9 26 45.6 .04

Not Married

Education

< High School

> = High School

32

23

34

56.1

40.4

59.6

31

6

51

54.4

10.5

89.5

13 37***

Notes: *p < .05, **p < .01, ***p < .001

92

Table 5


Health Condition Older Adult Group Matched Control Group

Number % Number %

Arthritis 32 56.1 8 14.0

Cancer 4 7.0 2 3.5

Diabetes 3 5.3 2 3.5

Hearing Problems 15 26.3 5 8.8

Heart Disease 10 17.5 0 0

High Blood Pressure 25 43.9 4 7.0

Kidney Disease 1 1.8 0 0

Osteoporosis 18 31.7 0 0

Parkinson's Disease 1 1.8 0 0

Respiratory Disease 8 14.0 1 1.8

Stroke 4 7.0 0 0

Vision Problems 11 19.3 7 12.3

93

Table 5


Health Condition

Arthritis

Cancer

Diabetes

Hearing Problems

Heart Disease

High Blood Pressure

Kidney Disease

Osteoporosis

Parkinson's Disease

Respiratory Disease

Stroke

Vision Problems

Older Adult

Number

32

4

3

15

10

25

1

18

1

8

4

11

Group

%

56.1

7.0

5.3

26.3

17.5

43.9

1.8

31.7

1.8

14.0

7.0

19.3

Matched Control Group

Number

8

2

2

5

0

4

0

0

0

1

0

7

%

14.0

3.5

3.5

8.8

0

7.0

0

0

0

1.8

0

12.3

93

no outlying data points identified. Next, the pattern of missing data was examined and

mean substitution was used to replace the missing value in those instances where the

missing data appeared to be the result of random occurrence. In cases where the

participants did not complete one whole questionnaire or left blank more than two

questions in a row, then the missing information was not altered. Normality, linearity and

homoscedasticity were examined via histograms and scatterplots, and no substantial

deviations were noted.

94

no outlying data points identified. Next, the pattern of missing data was examined and

mean substitution was used to replace the missing value in those instances where the

missing data appeared to be the result of random occurrence. In cases where the

participants did not complete one whole questionnaire or left blank more than two

questions in a row, then the missing information was not altered. Normality, linearity and

homoscedasticity were examined via histograms and scatterplots, and no substantial

deviations were noted.

94

3. RESULTS

3.1 Study 1

3.1.1 Preliminary Analyses

Means and standard deviations for each dependent variable (DV) and each

subscale, at each time of measurement for each group are reported in Tables 6, 7, and 8.

Reliability analyses on the following pre-treatment measures showed good internal

consistency: WI a = .81; SHAI a = .80; IAS a = .82, IAS-Fear of Illness and Pain a = .71,

IAS-Symptom Effects a = .70, HCQ a = .82; ASI a = .87; STAI-S a = .93; STAI-T a =

.91; GDS a = .88; GPM a = .82; SF-12 a = .83; WAI-Tasks a — .86, WAI-Bond a = .85,

WAI-Goal a = .87; and NML-2: Preparedness a = .72. Reliability analyses on the

following pre-treatment measures showed acceptable internal consistency: WI-Somatic

Symptoms/Bodily Preoccupation a = .68; WI-Disease Fear/Phobia a = .68; WI- SSI a =

.61; SSAS a = .69; NML-2: Distress a = .68 NML-2: Doubt a = .68; SHAI-Negative

Consequences Subscale a = .63; IAS-Treatment Experience a = .60; and IAS-Disease

Conviction a = .64; (Zinbarg, Revelle, Yovel, & Li, 2005).

Correlations among measures were assessed at pre-treatment and are provided in

Table 9. Examination of the correlation matrix indicates that many of the questionnaires

were significantly related to one another. Further, a number of the health anxiety

measures were found to be correlated. Specifically, the WI was found to moderately

correlate with the other two measures of health anxiety — the SHAI and the IAS —

suggesting that those participants with elevated health anxiety on the WI were more

95

3. RESULTS

3.1 Study 1

3.1.1 Preliminary Analyses

Means and standard deviations for each dependent variable (DV) and each

subscale, at each time of measurement for each group are reported in Tables 6, 7, and 8.

Reliability analyses on the following pre-treatment measures showed good internal

consistency: WI a = .81; SHAI a = .80; IAS a = .82, IAS-Fear of Illness and Pain a = .71,

IAS-Symptom Effects a = .70, HCQ a = .82; ASI a = .87; STAI-S a = .93; STAI-T a =

.91; GDS a = .88; GPM a = .82; SF-12 a = .83; WAI-Tasks a = .86, WAI-Bond a = .85,

WAI-Goal a = .87; and NML-2: Preparedness a = .72. Reliability analyses on the

following pre-treatment measures showed acceptable internal consistency: Wl-Somatic

Symptoms/Bodily Preoccupation a = .68; WI-Disease Fear/Phobia a = .68; WI- SSI a =

.61; SSAS a = .69; NML-2: Distress a = .68 NML-2: Doubt a = .68; SHAI-Negative

Consequences Subscale a = .63; IAS-Treatment Experience a = .60; and IAS-Disease

Conviction a = .64; (Zinbarg, Revelle, Yovel, & Li, 2005).

Correlations among measures were assessed at pre-treatment and are provided in

Table 9. Examination of the correlation matrix indicates that many of the questionnaires

were significantly related to one another. Further, a number of the health anxiety

measures were found to be correlated. Specifically, the WI was found to moderately

correlate with the other two measures of health anxiety - the SHAI and the IAS -

suggesting that those participants with elevated health anxiety on the WI were more

95

Table 6

Means and Standard Deviations for Primary and Secondary Outcome Measures

Measure SCBT (N = 21) ECBT (N = 18) WLC (N = 18)

Mean SD Mean SD Mean SD

Whiteley Index

Pre-treatment 8.86 1.28 9.39 1.20 9.11 1.18

Post-treatment 4.95 3.23 6.28 3.63 8.50 1.38

Follow-up 4.62 2.46 5.17 2.73

Short Health Anxiety Inventory

Pre-treatment 14.07 4.52 17.37 4.93 16.82 5.30

Post-treatment 11.63 4.01 15.11 6.29 16.00 4.41

Follow-up 11.45 2.90 13.78 5.24

Illness Attitudes Scale

Pre-treatment 45.43 12.61 54.04 9.29 49.75 10.19

Post-treatment 40.71 11.91 50.48 11.40 49.81 11.59

Follow-up 39.30 10.42 46.08 10.74

Somatic Symptom Inventory

Pre-treatment 31.68 7.52 31.88 6.74 31.27 7.37

Post-treatment 31.10 8.55 28.95 5.32 31.56 9.93

Follow-up 30.48 8.05 28.71 5.45

96

Table 6

Means and Standard Deviations for Primary and Secondary Outcome Measures

Measure SCBT(#=21) ECBT(JV=18) WLC (TV =18)


Whiteley Index

Pre-treatment 8.86 1.28 9.39 1.20 9.11 1.18

Post-treatment 4.95 3.23 6.28 3.63 8.50 1.38

Follow-up 4.62 2.46 5.17 2.73


Pre-treatment 14.07 4.52 17.37 4.93 16.82 5.30

Post-treatment 11.63 4.01 15.11 6.29 16.00 4.41

Follow-up 11.45 2.90 13.78 5.24


Pre-treatment 45.43 12.61 54.04 9.29 49.75 10.19

Post-treatment 40.71 11.91 50.48 11.40 49.81 11.59

Follow-up 39.30 10.42 46.08 10.74

Somatic Symptom Inventory

Pre-treatment 31.68 7.52 31.88 6.74 31.27 7.37

Post-treatment 31.10 8.55 28.95 5.32 31.56 9.93

Follow-up 30.48 8.05 28.71 5.45

96


Mean SD

Somatosensory Amplification Scale

Mean SD Mean SD

Pre-treatment 28.91 5.85 28.47 4.91 27.33 6.08

Post-treatment 27.86 5.68 27.29 7.02 27.03 4.66

Follow-up 27.86 5.91 25.48 4.42

Health Cognitions Questionnaire

Pre-treatment 29.29 10.01 29.78 7.59 29.11 8.16

Post-treatment 26.62 8.18 28.47 6.68 25.91 7.42

Follow-up 26.34 6.43 26.87 7.94

Anxiety Sensitivity Index

Pre-treatment 26.60 12.41 28.59 9.37 28.94 10.09

Post-treatment 23.10 9.83 24.59 11.27 29.86 10.84

Follow-up 22.16 9.24 20.89 9.29

State Trait Anxiety Inventory - State Scale

Pre-treatment 41.65 11.04 38.63 10.01 42.75 10.25

Post-treatment 36.24 9.90 36.87 8.29 39.80 10.61

Follow-up 40.30 10.09 34.71 8.89

State Trait Anxiety Inventory - Trait Scale

Pre-treatment 45.31 10.67 44.32 10.44 44.26 9.10

Post-treatment 41.53 10.47 42.98 8.00 42.50 10.44

Follow-up 40.30 10.09 40.82 9.32

97

Measure SCBT (TV =21) ECBT(N=18) WLC(JV=18)


Somatosensory Amplification Scale

Pre-treatment 28.91 5.85 28.47 4.91 27.33 6.08

Post-treatment 27.86 5.68 27.29 7.02 27.03 4.66

Follow-up 27.86 5.91 25.48 4.42

Health Cognitions Questionnaire

Pre-treatment 29.29 10.01 29.78 7.59 29.11 8.16

Post-treatment 26.62 8.18 28.47 6.68 25.91 7.42

Follow-up 26.34 6.43 26.87 7.94


Pre-treatment 26.60 12.41 28.59 9.37 28.94 10.09

Post-treatment 23.10 9.83 24.59 11.27 29.86 10.84

Follow-up 22.16 9.24 20.89 9.29

State Trait Anxiety Inventory - State Scale

Pre-treatment 41.65 11.04 38.63 10.01 42.75 10.25

Post-treatment 36.24 9.90 36.87 8.29 39.80 10.61

Follow-up 40.30 10.09 34.71 8.89

State Trait Anxiety Inventory - Trait Scale

Pre-treatment 45.31 10.67 44.32 10.44 44.26 9.10

Post-treatment 41.53 10.47 42.98 8.00 42.50 10.44

Follow-up 40.30 10.09 40.82 9.32

97



Geriatric Depression Scale

Pre-treatment 13.28 7.53 14.37 6.16 11.45 5.41

Post-treatment 10.23 8.61 10.92 6.34 10.46 6.00

Follow-up 10.22 8.26 10.61 4.97

Geriatric Pain Measure

Pre-treatment 18.04 11.25 18.78 11.84 18.90 11.04

Post-treatment 17.26 11.17 16.42 10.96 20.36 9.39

Follow-up 17.90 11.65 14.80 9.43

Short-Form 12 - Physical Summary Score

Pre-treatment 39.47 11.60 37.36 13.58 43.48 10.72

Post-treatment 42.00 11.55 38.68 13.07 40.41 11.04

Follow-up 39.49 12.71 40.11 15.20

Short-Form 12 - Mental Summary Score

Pre-treatment 42.02 11.69 43.96 10.61 43.53 11.04

Post-treatment 46.05 9.85 47.21 6.91 44.54 11.62

Follow-up 44.70 11.11 48.67 10.32



98

Measure SCBT(N=21) ECBT(iV=18) WLC(N=18)


Geriatric Depression Scale

Pre-treatment 13.28 7.53 14.37 6.16 11.45 5.41

Post-treatment 10.23 8.61 10.92 6.34 10.46 6.00

Follow-up 10.22 8.26 10.61 4.97


Pre-treatment 18.04 11.25 18.78 11.84 18.90 11.04

Post-treatment 17.26 11.17 16.42 10.96 20.36 9.39

Follow-up 17.90 11.65 14.80 9.43

Short-Form 12 - Physical Summary Score

Pre-treatment 39.47 11.60 37.36 13.58 43.48 10.72

Post-treatment 42.00 11.55 38.68 13.07 40.41 11.04

Follow-up 39.49 12.71 40.11 15.20

Short-Form 12 - Mental Summary Score

Pre-treatment 42.02 11.69 43.96 10.61 43.53 11.04

Post-treatment 46.05 9.85 47.21 6.91 44.54 11.62

Follow-up 44.70 11.11 48.67 10.32



98

Table 7

Means and Standard Deviations for WI, SHAI, and IAS Subscales



Whiteley Index - Somatic Symptoms/Bodily Preoccupation

Pre-treatment 1.33 .91 1.89 .90 1.89 .90

Post-treatment .71 .90 1.33 1.24 1.72 .89

Follow-up .52 .87 1.00 1.14

Whiteley Index - Disease Fear/Phobia

Pre-treatment 2.71 .46 2.67 .49 2.72 .46

Post-treatment 1.57 1.07 2.00 1.08 2.61 .61

Follow-up 1.52 1.12 1.61 1.09

SHAI - Negative Consequences

Pre-treatment 3.57 2.37 4.27 2.25 3.16 2.42

Post-treatment 2.56 2.07 3.60 2.18 3.10 2.22

Follow-up 2.50 1.83 2.98 2.38

Illness Attitudes Scale - Fear of Illness and Pain

Pre-treatment 11.87 6.40 15.35 5.01 13.28 5.30

Post-treatment 10.52 6.61 14.81 6.39 14.67 6.53

Follow-up 9.82 5.19 13.61 6.16

99

Table 7

Means and Standard Deviations for WI, SHAI, and IAS Subscales

Measure SCBT(7V=21) ECBT (N = 18) WLC (N = 18)

Mean SD Mean SD

Whiteley Index - Somatic Symptoms/Bodily Preoccupation

Pre-treatment 1.33 .91 1.89 .90

Post-treatment .71 .90

Follow-up .52 .87

Whiteley Index - Disease Fear/Phobia

Pre-treatment 2.71 .46

Post-treatment 1.57 1.07

Follow-up 1.52 1.12

SHAI - Negative Consequences

Pre-treatment 3.57 2.37

Post-treatment 2.56 2.07

Pre-treatment

Post-treatment

11.87 6.40

10.52 6.61

1.33

1.00

2.67

2.00

1.61

4.27

3.60

Follow-up 2.50 1.83 2.98

Illness Attitudes Scale - Fear of Illness and Pain

15.35

14.81

1.24

1.14

.49

1.08

1.09

2.25

2.18

2.38

Mean SD

1.89

1.72

2.72

2.61

3.16

3.10

.90

.89

.46

.61

2.42

2.22

5.01 13.28 5.30

6.39 14.67 6.53

Follow-up 9.82 5.19 13.61 6.16

99




- Symptom Effects

Pre-treatment 6.24 3.16 6.89 3.25 6.97 1.93

Post-treatment 4.90 3.19 6.83 3.24 6.53 2.92

Follow-up 4.72 2.82 6.00 3.12

Illness Attitudes Scale - Disease Conviction

Pre-treatment 4.12 3.08 5.95 3.20 5.00 2.43

Post-treatment 3.02 3.12 4.77 3.06 4.61 2.45

Follow-up 3.04 2.57 3.91 2.84

Illness Attitudes Scale - Treatment Experience

Pre-treatment 8.77 2.97 9.85 2.03 9.06 2.75

Post-treatment 8.76 2.64 9.28 3.02 8.17 2.06

Follow-up 8.52 2.87 8.66 2.44



100

Measure SCBT(iV=21) ECBT (TV =18) WLC (TV =18)


Illness Attitudes Scale - Symptom Effects

Pre-treatment 6.24 3.16 6.89 3.25 6.97 1.93

Post-treatment 4.90 3.19 6.83 3.24 6.53 2.92

Follow-up 4.72 2.82 6.00 3.12

Illness Attitudes Scale - Disease Conviction

Pre-treatment 4.12 3.08 5.95 3.20 5.00 2.43

Post-treatment 3.02 3.12 4.77 3.06 4.61 2.45

Follow-up 3.04 2.57 3.91 2.84

Illness Attitudes Scale - Treatment Experience

Pre-treatment 8.77 2.97 9.85 2.03 9.06 2.75

Post-treatment 8.76 2.64 9.28 3.02 8.17 2.06

Follow-up 8.52 2.87 8.66 2.44



100

Table 8

Means and Standard Deviations for WAI and NML-2 Subscales

Measure SCBT (N = 20) ECBT (N = 18)

Mean SD Mean SD

Working Alliance Inventory - Tasks

Session 1 72.20 9.40 71.22 7.35

Session 3 72.20 8.08 71.56 10.09

Session 6 75.00 8.57 72.17 10.77

Working Alliance Inventory - Bond

Session 1 76.09 6.97 74.36 7.30

Session 3 75.45 6.64 75.07 7.17

Session 6 75.75 7.83 72.71 3.32

Working Alliance Inventory - Goal

Session 1 71.91 9.62 71.94 7.45

Session 3 72.83 9.14 71.81 9.71

Session 6 75.55 9.37 71.38 10.76

Nijmegen Motivation List-2 - Preparedness

Session 1 46.95 6.55 48.17 5.66

Session 3 48.42 6.09 45.48 8.92

Session 6 48.68 5.01 46.05 8.62

101

Table 8

Means and Standard Deviations for WAI and NML-2 Subscales

Measure SCBT(N=20) ECBT (#=18)

Mean

Working Alliance Inventory - Tasks

Session 1

Session 3

Session 6

Working Alliance Inventory - Bond

Session 1 76.09

Session 3

Session 6

75.45

75.75

Working Alliance Inventory - Goal

Session 1 71.91

Session 3

Session 6

72.83

75.55

SD

6.97

6.64

7.83

9.62

9.14

9.37

Nijmegen Motivation List-2 - Preparedness

Session 1 46.95 6.55

Session 3

Session 6

48.42

48.68

6.09

5.01

Mean

74.36

75.07

72.71

SD

- Tasks

72.20

72.20

75.00

9.40

8.08

8.57

71.22

71.56

72.17

7.35

10.09

10.77

7.30

7.17

3.32

71.94

71.81

71.38

7.45

9.71

10.76

48.17

45.48

46.05

5.66

8.92

8.62

101

Measure SCBT (N = 20) ECBT (N = 18)

Mean SD Mean SD

Nijmegen Motivation List-2 — Distress

Session 1 13.68 4.96 15.22 5.36

Session 3 13.16 4.96 14.61 4.34

Session 6 12.21 4.36 13.44 5.41

Nijmegen Motivation List-2 — Doubt

Session 1 14.08 5.35 14.39 4.96

Session 3 13.87 5.28 13.75 4.40

Session 6 12.35 4.89 13.86 5.78


Behavioural Therapy

102

Measure SCBT (N = 20) ECBT (#=18)

Mean SD Mean SD

Nijmegen Motivation List-2 - Distress

Session 1 13.68 4.96 15.22 5.36

Session 3 13.16 4.96 14.61 4.34

Session 6 12.21 4.36 13.44 5.41

Nijmegen Motivation List-2 - Doubt

Session 1 14.08 5.35 14.39 4.96

Session 3 13.87 5.28 13.75 4.40

Session 6 12.35 4.89 13.86 5.78


Behavioural Therapy

102

Table 9

Correlations Between Measures at Pre-Treatment

WI SHAI IAS SSI SSAS HCQ ASI STAI-S STAI-T GDS GPM MCS PCS

WI -- .39** .50*** .03 -.07 .17 .11 .09 .12 .13 -.03 .05 -.24

SHAI .78*** .32* .14 .61*** .53*** .26 .23 .18 .15 -.19 .04

IAS .31* .33* .56*** .65*** .38** .41** .39** .07 -.13 -.16

SSI ---- .55*** .46*** .33* .12 .20 .20 .63*** -.46*** -.09

SSAS .21 .35** .23 .29* .22 .33* -.21 -.17

HCQ .52*** .24 .13 .08 .17 -.25 .07

ASI .49*** .37** .34* .08 -.08 -.09

STAI-S .71*** .53*** .01 .08 -.44**

STAI-T .81*** .19 -.06 -.69***

GDS .28* -.17 -.69***

GPM -.74*** -.10

MCS -.21

103

Table 9

Correlations Between Measures at Pre-Treatment

WI SHAI IAS SSI SSAS HCQ ASI STAI-S STAI-T GDS GPM MCS PCS

WI -- .39** .50*** .03 -.07 .17 .11 .09 .12 .13 -.03 .05 -.24

SHAI — .78*** .32* .14 .61*** .53*** .26 .23 .18 .15 -.19 .04

IAS — .31* .33* .56*** .65*** .38** .41** .39** .07 -.13 -.16

SSI — .55*** .46*** .33* .12 .20 .20 .63*** -.46*** -.09

SSAS — .21 .35** .23 .29* .22 .33* -.21 -.17

HCQ — .52*** .24 .13 .08 .17 -.25 .07

ASI — .49*** .37** .34* .08 -.08 -.09

STAI-S — .71*** .53*** .01 .08 -.44**

STAI-T — .81*** .19 -.06 -.69***

GDS -— .28* -.17 ..69***

GPM -— -.74*** _ 1 0

MCS -— -.21

103

Note. SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced Cognitive Behavioural Therapy; WLC = Wait-

List Control; WI = Whiteley Index; SHAI = Short Health Anxiety Inventory; IAS = Illness Attitudes Scale; SSI = Somatic

Symptoms Inventory; SSAS = Somatosensory Amplification Scale; HCQ = Health Cognitions Questionnaire; ASI = Anxiety

Sensitivity Index; STAI-S = State Trait Anxiety Inventory — State Scale; STAI-T = State Trait Anxiety Inventory — Trait Scale;

GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; PCS = Short-Form — 12 — Physical Summary Score; and

MCS = Short-Form — 12 — Mental Summary Score; * p < .05, ** p < .01, *** p < .001

104


List Control; WI = Whiteley Index; SHAI = Short Health Anxiety Inventory; IAS = Illness Attitudes Scale; SSI = Somatic

Symptoms Inventory; SSAS = Somatosensory Amplification Scale; HCQ = Health Cognitions Questionnaire; ASI = Anxiety

Sensitivity Index; STAI-S = State Trait Anxiety Inventory - State Scale; STAI-T = State Trait Anxiety Inventory - Trait Scale;

GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; PCS = Short-Form - 12 - Physical Summary Score; and

MCS = Short-Form - 12 - Mental Summary Score; * p < .05, ** p < .01, *** p < .001

104

likely to have increased health anxiety on the SHAI and IAS. The SHAI correlated

strongly with the IAS, HCQ, and ASI, and correlated moderately with the SSI, suggesting

those participants with elevated levels of health anxiety on the SHAI were more likely to

have increased health anxiety on the IAS, frequent hypochondriacal thoughts and

hypochondriacal somatic symptoms, and also experience bodily sensations as being

distressing. The IAS correlated strongly with the HCQ and ASI, and correlated

moderately with the SSI, SSAS, STAI-S, STAI-T, and GDS, suggesting that those

participants with elevated health anxiety on the IAS were more likely to have increased

hypochondriacal somatic symptoms, state and trait anxiety symptoms, and depressive

symptoms.

3.1.2 Testing Hypothesis 1

In order to test Hypothesis 1, 3 (treatment: SCBT, ECBT, WLC) x 2 (time: pre-

treatment and post-treatment) mixed factor ANCOVAs were conducted on each of these

DVs including the WI, SHAI, IAS, SSAS, SSI, and HCQ, with the pre-treatment value of

the measure of interest in the analysis set as the covariate. The independent variables

included one between groups variable, time, with two levels (pre-treatment and post-

treatment) and one within subject variable, group, with three levels (SCBT, ECBT, and

WLC).

The results from the mixed factor ANCOVAs assessing change in each primary

outcome measure, across all three groups from pre-treatment to post-treatment are shown

in Table 10. (Note: Treatment main effects are not reported in the table as the treatment

main effects are not of interest and do not provide relevant information; Huck &

105

likely to have increased health anxiety on the SHAI and IAS. The SHAI correlated

strongly with the IAS, HCQ, and ASI, and correlated moderately with the SSI, suggesting

those participants with elevated levels of health anxiety on the SHAI were more likely to

have increased health anxiety on the IAS, frequent hypochondriacal thoughts and

hypochondriacal somatic symptoms, and also experience bodily sensations as being

distressing. The IAS correlated strongly with the HCQ and ASI, and correlated

moderately with the SSI, SSAS, STAI-S, STAI-T, and GDS, suggesting that those

participants with elevated health anxiety on the IAS were more likely to have increased

hypochondriacal somatic symptoms, state and trait anxiety symptoms, and depressive

symptoms.

3.1.2 Testing Hypothesis 1

In order to test Hypothesis 1, 3 (treatment: SCBT, ECBT, WLC) x 2 (time: pre-

treatment and post-treatment) mixed factor ANCOVAs were conducted on each of these

DVs including the WI, SHAI, IAS, SSAS, SSI, and HCQ, with the pre-treatment value of

the measure of interest in the analysis set as the covariate. The independent variables

included one between groups variable, time, with two levels (pre-treatment and post-

treatment) and one within subject variable, group, with three levels (SCBT, ECBT, and

WLC).

The results from the mixed factor ANCOVAs assessing change in each primary


in Table 10. (Note: Treatment main effects are not reported in the table as the treatment


105

Table 10

Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Primary Outcome Measures

Measure Time Time x Covariate Time x Treatment

F p 112 F P ri2 F p i2

WI .305 .58 .006 .13 .73 .002 7.43 .001** .22

SHAI 1.97 .17 .04 7.36 .009** .12 2.97 .06 .10

IAS 4.26 .04* .07 6.82 .01* .11 2.31 .11 .08

SSI 1.50 .23 .03 3.27 .08 .06 1.26 .29 .05

SSAS 10.87 .002** .17 13.01 .001*** .20 .05 .95 .002

HCQ 6.52 .01* .11 10.62 .002** .17 1.06 .36 .04


Behavioural Therapy; WLC = Wait-List Control; WI = Whiteley Index; SHAI = Short

Health Anxiety Inventory; IAS = Illness Attitudes Scale; SSI = Somatic Symptom

Inventory; SSAS = Somatosensory Amplification Scale; HCQ - Health Cognitions

Questionnaire; * p < .05, ** p < .01, *** p < .001

106

Table 10

Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Primary Outcome Measures


WI

SHAI

IAS

SSI

SSAS

HCQ

F

.305

1.97

4.26

1.50

10.87

6.52

P

.58

.17

.04*

.23

.002**

.01*

r,2

.006

.04

.07

.03

.17

.11

F

.13

7.36

6.82

3.27

13.01

10.62

P

.73

.009**

.01*

.08

.001***

.002**

r,2

.002

.12

.11

.06

.20

.17

F

7.43

2.97

2.31

1.26

.05

1.06

P

.001**

.06

.11

.29

.95

.36

r,2

.22

.10

.08

.05

.002

.04




Inventory; SSAS = Somatosensory Amplification Scale; HCQ = Health Cognitions

Questionnaire; * p < .05, **p<. 01, ***/?<. 001

106

MacLean, 1975). These analyses revealed main effects for time on the IAS (p = .04),

SSAS (p = .002), and HCQ (p = .01). In addition, the covariate (i.e., the pre-treatment

value of the measure of interest in the analysis) was significantly related to outcome at

post-treatment on the SHAI (p = .009), IAS (p = .01), SSAS (p = .001), and HCQ (p =

.002). Of particular interest were the interactions between group and time, after

controlling for the variability in pre-treatment scores. In this case, a statistically

significant time x treatment group interaction was found on the WI (p = .001). Figure 4

depicts the significant findings of the 3 x 2 analyses.

To examine the interaction further, 2 (treatment: SCBT and ECBT or WLC) x 2

(time: pre-treatment and post-treatment) repeated measures ANCOVAs were conducted

to determine specifically how treatment conditions influenced the DVs over time. More

specifically, the SCBT condition was compared to the WLC condition, the ECBT

condition was compared to the WLC condition, and the SCBT and ECBT conditions

were compared to each other. The pre-treatment value of the measure of interest in each

analysis was set as the covariate. Table 11 shows the results of the 2 x 2 analyses (Note:

Treatment main effects are not reported in the table as the treatment main effects are not

of interest and do not provide relevant information; Huck & MacLean, 1975). After

controlling for the effect of the pre-treatment score on the measure of interest, from pre-

treatment and post-treatment, individuals in the SCBT group evidenced greater

improvements than did individuals in the WLC group on the WI (p = .0001). From pre-

treatment to post-treatment, individuals in the ECBT group also evidenced greater

107

MacLean, 1975). These analyses revealed main effects for time on the IAS (p = .04),

SSAS (p = .002), and HCQ (p = .01). In addition, the covariate (i.e., the pre-treatment

value of the measure of interest in the analysis) was significantly related to outcome at

post-treatment on the SHAI (p = .009), IAS (p = .01), SSAS (p = .001), and HCQ (p =

.002). Of particular interest were the interactions between group and time, after

controlling for the variability in pre-treatment scores. In this case, a statistically

significant time x treatment group interaction was found on the WI (p = .001). Figure 4

depicts the significant findings of the 3 x 2 analyses.

To examine the interaction further, 2 (treatment: SCBT and ECBT or WLC) x 2

(time: pre-treatment and post-treatment) repeated measures ANCOVAs were conducted

to determine specifically how treatment conditions influenced the DVs over time. More

specifically, the SCBT condition was compared to the WLC condition, the ECBT

condition was compared to the WLC condition, and the SCBT and ECBT conditions

were compared to each other. The pre-treatment value of the measure of interest in each

analysis was set as the covariate. Table 11 shows the results of the 2 x 2 analyses (Note:


of interest and do not provide relevant information; Huck & MacLean, 1975). After

controlling for the effect of the pre-treatment score on the measure of interest, from pre-

treatment and post-treatment, individuals in the SCBT group evidenced greater

improvements than did individuals in the WLC group on the WI (p = .0001). From pre-

treatment to post-treatment, individuals in the ECBT group also evidenced greater

107

10

9

8

7

6

5

4

3

2

1

0

Pre Post

- • —'SCBT

ECBT

—A—WLC

Figure 4. Mean WI scores by treatment condition at pre-treatment and post-treatment.

(Treatment Conditions: SCBT = Standard Cognitive Behavioural Therapy; ECBT =

Enhanced Cognitive Behavioural Therapy; WLC = Wait-List Control). Original in

Colour.

108

3 -2 -1 -0 -J

Pre Post

Figure 4. Mean WI scores by treatment condition at pre-treatment and post-treatment.

(Treatment Conditions: SCBT = Standard Cognitive Behavioural Therapy; ECBT =


Colour.

108

Table 11

Comparisons from Pre- to Post-Treatment for Primary Dependent Variables

Measure Treatment Time Time x Covariate Time x Treatment

F p 112 F p Ti2 F p 112

WI SCBT vs ECBT 2.48 .12 .07 .42 .52 .01 .42 .52 .01

SCBT vs WLC 1.58 .22 .04 4.01 .051 .10 17.59 .0001*** .33

ECBT vs WLC .85 .36 .03 .13 .72 .004 9.63 .004** .23


List Control; WI = Whiteley Index; * p < .01, ** p < .001

109

Table 11

Comparisons from Pre- to Post-Treatment for Primary Dependent Variables


F p r|2 F p r|2 F p rj2

WI SCBT vs ECBT 2.48 A2 !(J7 4̂2 5̂2 M A2 S2. M

SCBT vs WLC 1.58 .22 .04 4.01 .051 .10 17.59 .0001*** .33

ECBT vs WLC .85 .36 .03 .13 .72 .004 9.63 .004** .23


List Control; WI = Whiteley Index; * p < .01, ** p < .001

109

improvements than did individuals in the WLC group on the WI (p = .004). There was

no difference between the SCBT and ECBT groups.

3.1.2.1 Subscale comparisons

Because the WI, SHAT, and IAS have subscales, secondary analyses focusing on

the two WI subscales (i.e., Somatic Symptoms/Bodily Preoccupation; Disease

Fear/Phobia), one SHAI subscale (i.e., Negative Consequences), and four IAS subscales

(i.e., Fear of Illness and Pain, Symptom Effects, Treatment Experience, Disease

Conviction) were conducted in order to determine if the constructs measured by the

specific subscales were differentially affected by treatment condition over time. Seven 3

(treatment) x 2 (time) repeated measures ANCOVAs were conducted utilizing the above-

listed subscales as the DVs. The pre-treatment value of the measure of interest in each

analysis was set as the covariate. (Note: Treatment main effects are not reported in the

table as the treatment main effects are not of interest and do not provide relevant

information; Huck & MacLean, 1975).

The results indicated main effects for time on IAS-Disease Conviction (p = .01.

In addition, the covariate (i.e., the pre-treatment value of the measure of interest in the

analysis) was significantly related to outcome at post-treatment on the WI-Somatic

Symptoms/Bodily Preoccupation (p = .001), SHAI-Negative Consequences (p = .003),

and IAS-Fear of Illness and Pain (p = .04). Of relevance, there were time by treatment

interactions on WI-Disease Fear/Phobia (p = .002), after controlling for the effect of the

pre-treatment score on the measure of interest. See Table 12 for the results.

110

improvements than did individuals in the WLC group on the WI (p = .004). There was

no difference between the SCBT and ECBT groups.

3.1.2.1 Subscale comparisons

Because the WI, SHAI, and IAS have subscales, secondary analyses focusing on

the two WI subscales (i.e., Somatic Symptoms/Bodily Preoccupation; Disease

Fear/Phobia), one SHAI subscale (i.e., Negative Consequences), and four IAS subscales

(i.e., Fear of Illness and Pain, Symptom Effects, Treatment Experience, Disease

Conviction) were conducted in order to determine if the constructs measured by the

specific subscales were differentially affected by treatment condition over time. Seven 3

(treatment) x 2 (time) repeated measures ANCOVAs were conducted utilizing the above-

listed subscales as the DVs. The pre-treatment value of the measure of interest in each

analysis was set as the covariate. (Note: Treatment main effects are not reported in the

table as the treatment main effects are not of interest and do not provide relevant

information; Huck & MacLean, 1975).

The results indicated main effects for time on IAS-Disease Conviction (p = .01.

In addition, the covariate (i.e., the pre-treatment value of the measure of interest in the

analysis) was significantly related to outcome at post-treatment on the Wl-Somatic

Symptoms/Bodily Preoccupation (p = .001), SHAI-Negative Consequences (p = .003),

and LAS-Fear of Illness and Pain (p = .04). Of relevance, there were time by treatment

interactions on WI-Disease Fear/Phobia (p = .002), after controlling for the effect of the

pre-treatment score on the measure of interest. See Table 12 for the results.

110

Table 12

Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for WI, SHAI, and IAS Subscales


112

WI - SS 1.95 .17 .04 12.19 .001** .19 2.83 .07 .10

WI - DF .66 .42 .01 .02 .89 .0001 7.14 .002** .21

SHAI - NC 1.66 .20 .03 9.96 .003** .16 2.23 .12 .08

IAS - Fear 3.38 .07 .06 4.36 .04* .08 1.83 .17 .07

IAS - Eff .21 .65 .004 2.23 .14 .04 2.61 .08 .09

IAS - Exp 2.68 .11 .05 12.65 .001 .38 .99 .38 .04

IAS - Con 6.83 .01* .11 10.55 .002 .17 .85 .43 .03


List Control; WI - SS = Whiteley Index - Somatic Symptoms/Bodily Preoccupation; WI - DF = Whiteley Index - Disease

Fear/Phobia; SHAI - NC = Short Health Anxiety Inventory - Negative Consequences; IAS - Fear = Illness Attitudes Scale -

111

Table 12

Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for WI, SHAI, and IAS Subscales


WI-SS

WI-DF

SHAI - NC

IAS - Fear

IAS - Eff

IAS - Exp

IAS - Con

F

1.95

.66

1.66

3.38

.21

2.68

6.83

P

.17

.42

.20

.07

.65

.11

.01*

r,2

.04

.01

.03

.06

.004

.05

.11

F

12.19

.02

9.96

4.36

2.23

12.65

10.55

P

.001**

.89

.003**

.04*

.14

.001

.002

r,2

.19

.0001

.16

.08

.04

.38

.17

F

2.83

7.14

2.23

1.83

2.61

.99

.85

P

.07

.002**

.12

.17

.08

.38

.43

r,2

.10

.21

.08

.07

.09

.04

.03



Fear/Phobia; SHAI - NC = Short Health Anxiety Inventory — Negative Consequences; IAS - Fear = Illness Attitudes Scale -

111

Fear of Illness and Pain; IAS — Eff = Illness Attitudes Scale — Symptom Effects; IAS — Exp = Illness Attitudes Scale —

Treatment Experience; IAS — Con = Illness Attitudes Scale — Disease Conviction; * p < .05, ** p < .01, *** p < .001

112

Fear of Illness and Pain; IAS - Eff = Illness Attitudes Scale - Symptom Effects; IAS - Exp = Illness Attitudes Scale -

Treatment Experience; IAS - Con = Illness Attitudes Scale - Disease Conviction; * p < .05, ** p < .01, *** p < .001

112

Table 13

Comparisons from Pre- to Post-Treatment for WI Subscale


F p n2 F p t12 F p 112

WI-DF SCBT vs ECBT 3.42 .07 .09 .67 .42 .11 2.77 .105 .07

SCBT vs WLC .03 .86 .001 .38 .54 .01 15.46 .0001*** .30

ECBT vs WLC .04 .84 .001 .49 .49 .02 4.43 .04* .12


List Control; WI — DF = Whiteley Index — Disease Fear/Phobia; * p < .05,* p < .01, ** p < .001

113

Table 13

Comparisons from Pre- to Post-Treatment for WI Subscale


F p r|2 F p r|2 F P ^2

WI-DF SCBT vs ECBT 3.42 0̂7 !(J9 67 4̂2 H 2/77 T05 !07

SCBT vs WLC .03 .86 .001 .38 .54 .01 15.46 .0001*** .30

ECBT vs WLC .04 .84 .001 .49 .49 .02 4.43 .04* .12


List Control; WI - DF = Whiteley Index - Disease Fear/Phobia; * p < .05,* p < .01, ** p < .001

113

To follow-up on the interaction effects, three 2 (treatment) x 2 (time) repeated

measures ANCOVAs showed that on the one WI subscale (see Table 13) (Note:


of interest and do not provide relevant information; Huck & MacLean, 1975), Disease

Fear/Phobia decreased significantly in the SCBT condition compared to the WLC

condition (p = .0001) and in the ECBT condition compared to the WLC condition (p =

.04), after controlling for the effect of the pre-treatment score on the measure of interest.

See Figure 5.

The above reported results provide evidence that there was a change from pre- to

post-treatment on one WI. More specifically, both the SCBT and ECBT groups

experienced a greater reduction in Disease Fear/Phobia than did the WLC group.


In order to test Hypothesis 1 with regard to the secondary outcome measures (i.e.,

participants receiving standard CBT and ECBT, but not those in WLC group, would

evidence improvements in anxiety sensitivity, state and trait anxiety, depression, pain,

and health-related quality of life from pre-treatment to post-treatment), seven 3

(treatment: SCBT and ECBT or WLC) x 2 (time: pre-treatment and post-treatment

(treatment) mixed factor ANCOVAs were conducted on each of the secondary outcome

measures including the ASI, STAI- S, STAI-T, GDS, GPM, SF-12-PCS, and SF-12-

MCS. The pre-treatment value of the measure of interest in each analysis was set as the

114

To follow-up on the interaction effects, three 2 (treatment) x 2 (time) repeated

measures ANCOVAs showed that on the one WI subscale (see Table 13) (Note:


of interest and do not provide relevant information; Huck & MacLean, 1975), Disease

Fear/Phobia decreased significantly in the SCBT condition compared to the WLC

condition (p = .0001) and in the ECBT condition compared to the WLC condition (p =


See Figure 5.

The above reported results provide evidence that there was a change from pre- to

post-treatment on one WI. More specifically, both the SCBT and ECBT groups

experienced a greater reduction in Disease Fear/Phobia than did the WLC group.


In order to test Hypothesis 1 with regard to the secondary outcome measures (i.e.,

participants receiving standard CBT and ECBT, but not those in WLC group, would

evidence improvements in anxiety sensitivity, state and trait anxiety, depression, pain,

and health-related quality of life from pre-treatment to post-treatment), seven 3

(treatment: SCBT and ECBT or WLC) x 2 (time: pre-treatment and post-treatment

(treatment) mixed factor ANCOVAs were conducted on each of the secondary outcome

measures including the ASI, STAI- S, STAI-T, GDS, GPM, SF-12-PCS, and SF-12-

MCS. The pre-treatment value of the measure of interest in each analysis was set as the

114

3

2.5

2

1.5

1

0.5

0

P re Post

—•— SCBT

—II— ECBT

—fr- W LC

Figure 5. Mean WI — Disease Fear/Phobia scores by treatment condition at pre-treatment

and post-treatment. (SCBT = Standard Cognitive Behavioural Therapy; ECBT =


Colour.

115

2.5

2

1.5

l H

0.5

0

Pre Post

Figure 5. Mean WI - Disease Fear/Phobia scores by treatment condition at pre-treatment

and post-treatment. (SCBT = Standard Cognitive Behavioural Therapy; ECBT =


Colour.

115

covariate. (Note: Treatment main effects are not reported in the table as the treatment


MacLean, 1975).

The results from the mixed factor ANCOVAs assessing change in each secondary


in Table 14. There were main effects for time on the STAI-S (p = .001), STAI-T (p =

.02), GPM (p = .02), and SF-12-MCS (p = .0001). In addition, the covariate (i.e., the pre-

treatment value of the measure of interest in the analysis) was significantly related to

outcome at post-treatment on the STAI-S (p = .0001), STAI-T (p = .004), GPM (p —

.006), and SF-12-MCS (p = .0001). Of particular interest, a statistically significant time x

treatment group interaction was found on the SF-12-PCS (p = .04), after controlling for

the effect of the pre-treatment score on the measure of interest. Figure 8 depicts the

significant findings of the 3 x 2 analyses.

Two (treatment: SCBT and ECBT or WLC) x 2 (time: pre-treatment and post-

treatment) repeated measures comparisons were conducted to examine the relevant

interaction effect further. Table 15 shows the results of the 2 x 2 analyses (Note:


of interest and do not provide relevant information; Huck & MacLean, 1975). From pre-

treatment to post-treatment, individuals in the SCBT group evidenced greater

improvements than did individuals in the WLC group on the SF-12-PCS (p = .002),

indicating an improvement in self-rated physical health.

116

covariate. (Note: Treatment main effects are not reported in the table as the treatment


MacLean, 1975).

The results from the mixed factor ANCOVAs assessing change in each secondary


in Table 14. There were main effects for time on the STAI-S (p = .001), STAI-T (p =

.02), GPM (p = .02), and SF-12-MCS (p = .0001). In addition, the covariate (i.e., the pre-

treatment value of the measure of interest in the analysis) was significantly related to

outcome at post-treatment on the STAI-S (p = .0001), STAI-T (p = .004), GPM (p =

.006), and SF-12-MCS (p = .0001). Of particular interest, a statistically significant time x

treatment group interaction was found on the SF-12-PCS (p = .04), after controlling for

the effect of the pre-treatment score on the measure of interest. Figure 8 depicts the

significant findings of the 3 x 2 analyses.

Two (treatment: SCBT and ECBT or WLC) x 2 (time: pre-treatment and post-

treatment) repeated measures comparisons were conducted to examine the relevant

interaction effect further. Table 15 shows the results of the 2 x 2 analyses (Note:


of interest and do not provide relevant information; Huck & MacLean, 1975). From pre-

treatment to post-treatment, individuals in the SCBT group evidenced greater

improvements than did individuals in the WLC group on the SF-12-PCS (p = .002),

indicating an improvement in self-rated physical health.

116

Table 14

Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Secondary Outcome Measures


F P 112 F P 1-12 F p n2

ASI 3.29 .08 .06 9.54 .003 .15 1.53 .23 .05

STAI-S 13.39 .001** .20 20.80 .0001*** .28 .69 .51 .03

STAI-T 5.42 .02* .09 9.00 .004** .15 .65 .53 .02

GDS .02 .90 .0001 4.16 .05 .07 .68 .51 .03

GPM 5.65 .02* .10 8.34 .006** .14 1.07 .35 .04

SF-12-PCS 4.23 .05 .07 4.19 .05 .07 3.58 .04* .12

SF-12-MCS 24.12 .0001*** .31 17.60 .0001*** .25 1.07 .35 .04


List Control; ASI = Anxiety Sensitivity Index; STAI-S = State Trait Anxiety Inventory - State Scale; STAI-T = State Trait

Anxiety Inventory - Trait Scale; GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; SF-12-PCS = Short-

Form-12 - Physical Summary Score; and MCS = Short-Form-12 - Mental Summary Score; * p < .05, ** p < .01, *** p < .001

117

Table 14

Mixed-Factor 3 (Treatment) x 2 (Time) ANCOVAs for Secondary Outcome Measures


F P ri2~ F P r^2 F p ^

ASI 3.29 ^08 M 9M M3 15 L53 23 0̂5

STAI-S 13.39 .001** .20 20.80 .0001*** .28 .69 .51 .03

STAI-T 5.42 .02* .09 9.00 .004** .15 .65 .53 .02

GDS .02 .90 .0001 4.16 .05 .07 .68 .51 .03

GPM 5.65 .02* .10 8.34 .006** .14 1.07 .35 .04

SF-12-PCS 4.23 .05 .07 4.19 .05 .07 3.58 .04* .12

SF-12-MCS 24.12 .0001*** .31 17.60 .0001*** .25 1.07 .35 .04


List Control; ASI = Anxiety Sensitivity Index; STAI-S = State Trait Anxiety Inventory - State Scale; STAI-T = State Trait

Anxiety Inventory - Trait Scale; GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; SF-12-PCS = Short-

Form-12 - Physical Summary Score; and MCS = Short-Form-12 - Mental Summary Score; * p < .05, ** p < .01, *** p < .001

117

50

45 -

40

35 -

30 -

25

Pre Post

"SCBT

ECBT

—2z— WIC

Figure 6. Mean SF-12-PCS scores by treatment condition at pre-treatment and post-

treatment. (SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced

Cognitive Behavioural Therapy; WLC = Wait-List Control). Original in Colour.

118

Pre Post

Figure 6. Mean SF-12-PCS scores by treatment condition at pre-treatment and post-

treatment. (SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced

Cognitive Behavioural Therapy; WLC = Wait-List Control). Original in Colour.

118

Table 15

Comparisons from Pre- to Post-Treatment for Secondary Outcome Measures


F p ri2 F P ri2 F p Ti2

SF-12-PCS SCBT vs ECBT 5.87 .02* .14 3.82 .06 .10 .56 .46 .02

SCBT vs WLC 1.10 .30 .03 1.40 .25 .04 11.19 .002** .24

ECBT vs WLC 2.00 .17 .06 2.96 .10 .08 2.54 .12 .07


List Control; SF-12-PCS = Short-Form-12 — Physical Summary Score; * p < .01, *** p < .001

119

Table 15

Comparisons from Pre- to Post-Treatment for Secondary Outcome Measures


F p TJ2 F P r̂ 2 F p n T

SF-12-PCS SCBT vs ECBT 5.87 1)2* T4 3l*2 M TO 16 A6 1)2

SCBT vs WLC 1.10 .30 .03 1.40 .25 .04 11.19 .002** .24

ECBT vs WLC 2.00 .17 .06 2.96 .10 .08 2.54 .12 .07


List Control; SF-12-PCS = Short-Form-12 - Physical Summary Score; * p < .01, *** p < .001

119

3.1.3 Testing Hypotheses 2 and 3: Stability of Improvements

In keeping with the findings of Mohlman et al. (2003), participants treated with

ECBT were predicted to demonstrate the greatest overall improvement at post-treatment

and at three-month follow-up on each of the primary outcome and secondary outcome

measures indicated in the Hypothesis 1. For participants treated with both SCBT and

ECBT, all expected improvements were hypothesized to be maintained three months

following the conclusion of treatment.

Twenty 2 (treatment) x 2 (time) repeated measures ANCOVAs were conducted to

assess change from post-treatment to follow-up in both the SCBT and ECBT conditions

(see Tables 16, 17, and 18 for results of the analyses) (Note: Treatment main effects are

not reported in the table as the treatment main effects are not of interest and do not

provide relevant information; Huck & MacLean, 1975). The post-treatment value of the

measure of interest in each analysis was set as the covariate. The analyses revealed

statistically significant main effects for time on the WI (p = .004), SHAI (p = .002), IAS

(p = .01), SSAS (p = .001), IAS-Fear Illness and Pain (p = .03), IAS-Disease Conviction

(p = .02), STAI-S (p = .005), and GDS (p = .04). Of relevance, there were statistically

significant time by treatment effects for the STAI-State (p = .02) and the SF-12-PCS (p =


This indicated that from post-treatment to follow-up, individuals in the SCBT group

evidenced an increase in anxiety and the ECBT group evidenced a slight decline in

anxiety on the STAI-State. No other significant differences emerged.

120

3.1.3 Testing Hypotheses 2 and 3: Stability of Improvements

In keeping with the findings of Mohlman et al. (2003), participants treated with

ECBT were predicted to demonstrate the greatest overall improvement at post-treatment

and at three-month follow-up on each of the primary outcome and secondary outcome

measures indicated in the Hypothesis 1. For participants treated with both SCBT and

ECBT, all expected improvements were hypothesized to be maintained three months

following the conclusion of treatment.

Twenty 2 (treatment) x 2 (time) repeated measures ANCOVAs were conducted to

assess change from post-treatment to follow-up in both the SCBT and ECBT conditions

(see Tables 16, 17, and 18 for results of the analyses) (Note: Treatment main effects are

not reported in the table as the treatment main effects are not of interest and do not

provide relevant information; Huck & MacLean, 1975). The post-treatment value of the

measure of interest in each analysis was set as the covariate. The analyses revealed

statistically significant main effects for time on the WI (p = .004), SHAI (p = .002), IAS

(p = .01), SSAS (p = .001), IAS-Fear Illness and Pain (p = .03), LAS-Disease Conviction

(p = .02), STAI-S (p = .005), and GDS (p = .04). Of relevance, there were statistically

significant time by treatment effects for the STAI-State (p = .02) and the SF-12-PCS (p =


This indicated that from post-treatment to follow-up, individuals in the SCBT group

evidenced an increase in anxiety and the ECBT group evidenced a slight decline in

anxiety on the STAI-State. No other significant differences emerged.

120

Table 16

Comparisons from Post-Treatment to Follow-Up for the Primary Outcome Measures


F p i2 F P i2 F p 112

WI 9.26 .004** .21 27.13 .0001*** .43 .22 .64 .006

SHAI 10.60 .002** .23 18.42 .0001*** .34 .10 .75 .003

IAS 6.62 .01* .16 10.58 .002** .23 .04 .85 .001

SSI 3.58 .07 .09 4.48 .04* .11 .002 .97 .0001

SSAS 13.40 .001** .27 16.61 .0001*** .32 2.98 .09 .08

HCQ 3.09 .09 .08 5.15 .03* .13 .02 .89 .001


Behavioural Therapy; WLC = Wait-List Control; WI = Whiteley Index; SHAI = Health

Anxiety Index - Short-form; IAS = Illness Attitudes Scale; SSI = Somatic Symptom


Questionnaire; * p < .01, ** p < .001

121

Table 16

Comparisons from Post-Treatment to Follow-Up for the Primary Outcome Measures


WI

SHAI

IAS

SSI

SSAS

HCQ

F

9.26

10.60

6.62

3.58

13.40

3.09

P

.004**

.002**

.01*

.07

.001**

.09

r,2

.21

.23

.16

.09

.27

.08

F

27.13

18.42

10.58

4.48

16.61

5.15

P

.0001***

.0001***

.002**

.04*

.0001***

.03*

r,2

.43

.34

.23

.11

.32

.13

F

.22

.10

.04

.002

2.98

.02

P

.64

.75

.85

.97

.09

.89

r,2

.006

.003

.001

.0001

.08

.001


Behavioural Therapy; WLC = Wait-List Control; WI = Whiteley Index; SHAI = Health

Anxiety Index - Short-form; IAS = Illness Attitudes Scale; SSI = Somatic Symptom


Questionnaire; * p < .01, ** p < .001

121

Table 17

Comparisons from Post-Treatment to Follow-Up for the WI, SHAI, and IAS Subscales


F P i2 F P T12 F p 112

WI - SS 3.51 .07 .09 .56 .46 .02 .78 .38 .02

WI - DF .61 .44 .02 1.13 .30 .03 1.67 .20 .04

SHAI - NC 1.73 .20 .05 5.84 .02 .15 .19 .67 .01

IAS - Fear 5.20 .03* .13 11.96 .001** .25 .43 .51 .01

IAS - Eff 2.36 .13 .06 7.57 .01* .17 .11 .74 .003

IAS -Exp 3.31 .08 .08 5.88 .02 .14 .28 .60 .01

IAS - Con 5.62 .02* .14 15.75 .0001*** .30 .02 .89 .001



Fear/Phobia; SHAI - NC = Short Health Anxiety Inventory - Negative Consequences; IAS - Fear = Illness Attitudes Scale -


Treatment Experience; IAS - Con = Illness Attitudes Scale - Disease Conviction; * p < .01, ** p < .001

122

Table 17

Comparisons from Post-Treatment to Follow-Up for the WI, SHAI, and IAS Subscales

Measure

WI-SS

WI-DF

SHAI - NC

IAS - Fear

IAS - Eff

IAS - Exp

IAS - Con

F

3.51

.61

1.73

5.20

2.36

3.31

5.62

Time

P

.07

.44

.20

.03*

.13

.08

.02*

r,2

.09

.02

.05

.13

.06

.08

.14

F

.56

1.13

5.84

11.96

7.57

5.88

15.75

Time x Covariate

P

.46

.30

.02

.001**

.01*

.02

.0001***

r,2

.02

.03

.15

.25

.17

.14

.30

F

.78

1.67

.19

.43

.11

.28

.02

Time x Treatment

P

.38

.20

.67

.51

.74

.60

.89

r,2

.02

.04

.01

.01

.003

.01

.001



Fear/Phobia; SHAI - NC = Short Health Anxiety Inventory — Negative Consequences; IAS - Fear = Illness Attitudes Scale •


Treatment Experience; IAS - Con = Illness Attitudes Scale - Disease Conviction; * p < .01, ** p < .001

122

Table 18

Comparisons from Post-Treatment to Follow-Up for the Secondary Outcome Measures


F p 112 F P rl2 F p 112

ASI 7.27 .01 .17 15.08 .0001*** .30 1.02 .32 .03

STAI-S 9.03 .005** .20 8.41 .006** .19 5.79 .02* .14

STAI-T 2.20 .15 .06 3.02 .09 .08 1.15 .29 .03

GDS 4.66 .04* .12 8.19 .007** .19 .04 .85 .001

GPM 1.05 .31 .03 2.61 .12 .07 2.46 .13 .06

SF-12-PCS .21 .65 .01 .10 .76 .01 4.26 .04* .11

SF-12-MCS 1.12 .30 .03 1.15 .29 .03 1.32 .26 .04


Behavioural Therapy; WLC = Wait-List Control; ASI = Anxiety Sensitivity Index; STAI-

S = State Trait Anxiety Inventory - State Scale; STAI-T = State Trait Anxiety Inventory

- Trait Scale; GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; SF-12-

PCS = Short-Form-12 - Physical Summary Score; and MCS = Short-Form-12 - Mental

Summary Score; * p < .01, ** p < .001

123

Table 18

Comparisons from Post-Treatment to Follow-Up for the Secondary Outcome Measures


ASI

STAI-S

STAI-T

GDS

GPM

SF-12-PCS

SF-12-MCS

F

7.27

9.03

2.20

4.66

1.05

.21

1.12

P

.01

.005**

.15

.04*

.31

.65

.30

r,2

.17

.20

.06

.12

.03

.01

.03

F

15.08

8.41

3.02

8.19

2.61

.10

1.15

P

.0001***

.006**

.09

.007**

.12

.76

.29

r,2

.30

.19

.08

.19

.07

.01

.03

F

1.02

5.79

1.15

.04

2.46

4.26

1.32

P

.32

.02*

.29

.85

.13

.04*

.26

r,2

.03

.14

.03

.001

.06

.11

.04





PCS = Short-Form-12 - Physical Summary Score; and MCS = Short-Form-12 - Mental

Summary Score; * p < .01, ** p < .001

123

3.1.4 Hypothesis 4 and 5 — Therapeutic Alliance and Motivation for Psychotherapy

It was hypothesized that participants treated with ECBT would demonstrate

higher levels of therapeutic alliance and motivation for psychotherapy at three and six

weeks than those receiving SCBT. In order to test these hypotheses, 2 (treatment: SCBT,

ECBT) x 3 (time: Session 1, Session 3, Session 6) mixed factor ANCOVAs were

conducted on the WAI subscales (Tasks, Bond, Goals) and the NML-2 subscales

(Preparedness, Distress, Doubt). The Session 1 value of the measure of interest in each

analysis was set as the covariate. The results from the mixed factor ANCOVAs assessing

change in the WAI and NML-2 across both groups from Session 1 to Session 6 are shown

in Table 19. These analyses revealed a statistically significant main effect for time on the

WAI - Tasks (p = .02), NML-2-Preparedness (p = .047), NML-2-Distres (p = .02), and

NML-2-Doubt (p = .03). The covariate (i.e., the Session 1 value of the measure of

interest in the analysis) was significantly related to outcome at post-treatment on the

WAI-Bond (p = .02), NML-2-Preparedness (p = .044), NML-2-Distres (p = .004), and

NML-2-Doubt (p = .008), and a statistically significant time x treatment group interaction

on the WAI — Goals Subscale (p = .04).

To examine the interaction further, 2 (treatment: SCBT, ECBT) x 2 (time: Session

1, Session 3, or Session 6) repeated measures ANCOVAs were conducted to determine

specifically how treatment conditions influenced the DV over time. More specifically,

the SCBT condition was compared to the ECBT condition. The pre-treatment value of

the measure of interest in each analysis was set as the covariate. Table 20 shows the

124

3.1.4 Hypothesis 4 and 5 - Therapeutic Alliance and Motivation for Psychotherapy

It was hypothesized that participants treated with ECBT would demonstrate

higher levels of therapeutic alliance and motivation for psychotherapy at three and six

weeks than those receiving SCBT. In order to test these hypotheses, 2 (treatment: SCBT,

ECBT) x 3 (time: Session 1, Session 3, Session 6) mixed factor ANCOVAs were

conducted on the WAI subscales (Tasks, Bond, Goals) and the NML-2 subscales

(Preparedness, Distress, Doubt). The Session 1 value of the measure of interest in each

analysis was set as the covariate. The results from the mixed factor ANCOVAs assessing

change in the WAI and NML-2 across both groups from Session 1 to Session 6 are shown

in Table 19. These analyses revealed a statistically significant main effect for time on the

WAI - Tasks (p = .02), NML-2-Preparedness (p = .047), NML-2-Distres (p = .02), and

NML-2-Doubt (p = .03). The covariate (i.e., the Session 1 value of the measure of

interest in the analysis) was significantly related to outcome at post-treatment on the

WAI-Bond (p = .02), NML-2-Preparedness (p = .044), NML-2-Distres (p = .004), and

NML-2-Doubt (p = .008), and a statistically significant time x treatment group interaction

on the WAI - Goals Subscale (p = .04).

To examine the interaction further, 2 (treatment: SCBT, ECBT) x 2 (time: Session

1, Session 3, or Session 6) repeated measures ANCOVAs were conducted to determine

specifically how treatment conditions influenced the DV over time. More specifically,

the SCBT condition was compared to the ECBT condition. The pre-treatment value of

the measure of interest in each analysis was set as the covariate. Table 20 shows the

124

Table 19

Mixed-Factor 3 (Time) x 2 (Treatment) ANCOVAs for WAI and NML-2 Subscales


F P 112 F P i2 F p ri2

WAI - Tasks 2.68 .08 .14 3.09 .06 .15 1.52 .23 .08

WAI - Bond 4.67 .02* .22 4.58 .02* .21 1.12 .34 .06

WAI - Goals 1.03 .37 .06 1.09 .35 .06 3.62 .04* .18

NML-2 -

Preparedness 3.35 .047* .17 3.45 .044* .17 1.87 .17 .10

NML-2 - Distress 4.30 .02* .21 6.71 .004** .29 .10 .91 .006

NML-2 - Doubt 3.90 .03* .19 5.63 .008** .25 .85 .44 .05

Note. WAI-T = Working Alliance Inventory - Tasks Subscale; WAI-B = Working Alliance Inventory - Bond Subscale; WAI-

G = Working Alliance Inventory - Goals Subscale; NML-2 - P = Nijmegen Motivation List-2 - Preparedness Subscale; NML-

2 - Di = Nijmegen Motivation List-2 - Distress Subscale; NML-2 - P = Nijmegen Motivation List-2 - Doubt Subscale. * p <

.05, ** p <.01, ***p <.001

125

Table 19

Mixed-Factor 3 (Time) x 2 (Treatment) ANCOVAs for WAI and NML-2 Subscales

Measure

WAI-Tasks

WAI - Bond

WAI - Goals

NML-2 -

Preparedness

NML-2 - Distress

NML-2 - Doubt

F

2.68

4.67

1.03

3.35

4.30

3.90

Time

P

.08

.02*

.37

.047*

.02*

.03*

r,2

.14

.22

.06

.17

.21

.19

F

3.09

4.58

1.09

3.45

6.71

5.63

Time x Covariate

P

.06

.02*

.35

.044*

.004**

.008**

r,2

.15

.21

.06

.17

.29

.25

F

1.52

1.12

3.62

1.87

.10

.85

Time x Treatment

P

.23

.34

.04*

.17

.91

.44

r,2

.08

.06

.18

.10

.006

.05

Note. WAI-T = Working Alliance Inventory - Tasks Subscale; WAI-B = Working Alliance Inventory - Bond Subscale; WAI-

G = Working Alliance Inventory - Goals Subscale; NML-2 - P = Nijmegen Motivation List-2 - Preparedness Subscale; NML-

2 - Di = Nijmegen Motivation List-2 - Distress Subscale; NML-2 - P = Nijmegen Motivation List-2 - Doubt Subscale. * p <

.05, **/?<.01, ***/?<.001

125

Table 20

Comparisons from Session 1, Session 3, and Session 6 on the WAI-Goals Subscale

Measure Sessions Time Time x Covariate Time x Treatment

F p 712 F p i2 F p rig

WAI-Goals 1 to 3

SCBT vs ECBT 1.96 .17 .05 1.86 .18 .05 .29 .59 .01

3 to 6

SCBT vs ECBT .25 .62 .01 .08 .78 .002 5.74 .02* .14


List Control; SF-12-PCS = Short-Form-12 — Physical Summary Score; * p < .05

126

Table 20

Comparisons from Session 1, Session 3, and Session 6 on the WAI-Goals Subscale

Measure Sessions Time Time x Covariate Time x Treatment

F p r|2 F p r(l F p r|2

WAI-Goals 1 to 3

SCBT vs ECBT 1.96 .17 .05 1.86 .18 .05 .29 .59 .01

3 to 6

SCBT vs ECBT .25 .62 .01 .08 .78 .002 5.74 .02* .14


List Control; SF-12-PCS = Short-Form-12 - Physical Summary Score; * p < .05

126

results of the 2 x 3 analyses (Note: Treatment main effects are not reported in the table as

the treatment main effects are not of interest and do not provide relevant information;

Huck & MacLean, 1975). After controlling for the effect of the Session 3 score on the

measure of interest, from Session 3 to Session 6, individuals in the SCBT group

evidenced greater improvements than did individuals in the ECBT group on the WAI-

Goals (p = .02). These findings indicate that from Session 3 to Session 6, the WAI —

Goals Subscale score significantly increased in the SCBT group as compared to the

ECBT group. Figures 7 depict only the significant results of the 3 x 2 analyses.

3.1.5 Process and Significance of Change

3.1.5.1 Treatment Specific Change

The repeated measures factorial analyses consistently indicated a main effect for

time for many of the DVs amongst both the primary and secondary outcome measures.

Following other researchers (e.g., Greeven et al., 2007), paired-samples t-tests were

conducted on each DV for each treatment group to compare change from pre- to post-

treatment and post-treatment to follow-up in order to identify which treatment conditions

produced improvements on each DV. Tables 21, 22, and 23 illustrate the relevant data,

including Cohen's d effect sizes. Participants in the SCBT treatment group demonstrated

significant improvements from pre- to post-treatment on the WI (p = .0001), SHAI (p =

.001), IAS (p = .04), STAI-State (p = .01), STAI-Trait (p = .02), GDS (p = .02), SF-12-

PCS (p = .04), SF-12-MCS (p = .007), WI-Somatic Symptoms/Bodily Preoccupation (p

= .02), WI-Disease Fear/Phobia (p = .0001), SHAI-Negative Consequences (p = .02),

and IAS-Effects (p = .02). Participants in the ECBT treatment group demonstrated

127

results of the 2 x 3 analyses (Note: Treatment main effects are not reported in the table as

the treatment main effects are not of interest and do not provide relevant information;

Huck & MacLean, 1975). After controlling for the effect of the Session 3 score on the

measure of interest, from Session 3 to Session 6, individuals in the SCBT group

evidenced greater improvements than did individuals in the ECBT group on the WAI-

Goals (p = .02). These findings indicate that from Session 3 to Session 6, the WAI -

Goals Subscale score significantly increased in the SCBT group as compared to the

ECBT group. Figures 7 depict only the significant results of the 3 x 2 analyses.

3.1.5 Process and Significance of Change

3.1.5.1 Treatment Specific Change

The repeated measures factorial analyses consistently indicated a main effect for

time for many of the DVs amongst both the primary and secondary outcome measures.

Following other researchers (e.g., Greeven et al., 2007), paired-samples Mests were

conducted on each DV for each treatment group to compare change from pre- to post-

treatment and post-treatment to follow-up in order to identify which treatment conditions

produced improvements on each DV. Tables 21, 22, and 23 illustrate the relevant data,

including Cohen's d effect sizes. Participants in the SCBT treatment group demonstrated

significant improvements from pre- to post-treatment on the WI (p = .0001), SHAI (p —

.001), IAS (p = .04), STAI-State (p = .01), STAI-Trait (p = .02), GDS (p = .02), SF-12-

PCS (p = .04), SF-12-MCS (p = .007), Wl-Somatic Symptoms/Bodily Preoccupation (p

= .02), WI-Disease Fear/Phobia (p = .0001), SHAI-Negative Consequences (p = .02),

and IAS-Effects (p = .02). Participants in the ECBT treatment group demonstrated

127

76

75

74

73

72

71

70

69

Session 1 Session 2 Session 3

•••'"'SCBT

ECBT

Figure 7. Mean WAI - Goal scores by treatment condition at Session 1, Session 3, and

Session 6. (SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced

Cognitive Behavioural Therapy). Original in Colour.

128

'SCBT

•ECBT

Session 1 Session 2 Session 3

Figure 7. Mean WAI - Goal scores by treatment condition at Session 1, Session 3, and

Session 6. (SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced

Cognitive Behavioural Therapy). Original in Colour.

128

Table 21

Paired T-Tests for Each Primary Outcome Measure

Measure Comparisons t-test

Treatments Times T Df Sig (2 tailed) d

WI SCBT 1 vs 2 5.58 20 .000*** 1.63

2 vs 3 .79 20 .44 .12

ECBT 1 vs 2 4.60 17 .000*** 1.18

2 vs 3 2.08 17 .04* .36

WLC 1 vs 2 1.43 17 .17 .49

SHAI SCBT 1 vs 2 3.91 20 .001** .59

2 vs 3 .67 20 .51 .05

ECBT 1 vs 2 2.45 17 .03* .41

2 vs 3 1.69 17 .11 .24

WLC 1 vs 2 .82 17 .42 .17

IAS SCBT 1 vs 2 2.15 20 .04* .39

2 vs 3 .73 20 .47 .13

ECBT 1 vs 2 1.66 17 .11 .35

2 vs 3 2.60 17 .02* .41

WLC 1 vs 2 -.03 17 .98 .01

SSI SCBT 1 vs 2 .48 20 .64 .07

2 vs 3 .99 20 .34 .08

129

Table 21

Paired T-Tests for Each Primary Outcome Measure

Measure

WI

SHAI

IAS

SSI

Comparisons

Treatments

SCBT

ECBT

WLC

SCBT

ECBT

WLC

SCBT

ECBT

WLC

SCBT

Times

l v s 2

2vs3

1 vs2

2vs3

1 vs2

1 vs2

2vs3

1 vs2

2 v s 3

1 vs2

1 vs2

2vs3

l v s 2

2vs3

1 vs2

1 vs2

2vs3

T

5.58

.79

4.60

2.08

1.43

3.91

.67

2.45

1.69

.82

2.15

.73

1.66

2.60

-.03

.48

.99

/-test

Df

20

20

17

17

17

20

20

17

17

17

20

20

17

17

17

20

20

Sig (2 tailed)

.000***

.44

.000***

.04*

.17

.001**

.51

.03*

.11

.42

.04*

.47

.11

.02*

.98

.64

.34

d

1.63

.12

1.18

.36

.49

.59

.05

.41

.24

.17

.39

.13

.35

.41

.01

.07

.08

129



SSI ECBT 1 vs 2 3.16 17 .006** .50

2 vs 3 .22 17 .83 .05

WLC 1 vs 2 1.16 17 .26 .03

SSAS SCBT 1 vs 2 .85 20 .40 .19

2 vs 3 .000 20 1.00 .00

ECBT 1 vs 2 .79 17 .44 .20

2 vs 3 1.51 17 .15 .32

WLC 1 vs 2 .27 17 .79 .42

HCQ SCBT 1 vs 2 1.83 20 .08 .30

2 vs 3 .84 20 .41 .04

ECBT 1 vs 2 1.31 17 .21 .19

2 vs 3 1.36 17 .19 .22

WLC 1 vs 2 2.97 17 .79 .42





Questionnaire; * p < .05, ** p < .01, *** p < .001

130

Measure Comparisons Mest

Treatments Times T Df

SSI ECBT l v s 2 3.16 17

2 v s 3 .22 17

WLC l v s 2 1.16 17

SSAS SCBT 1 vs 2 .85 20

2 vs 3 .000 20

ECBT l v s 2 .79 17

2vs3 1.51 17

WLC l v s 2 .27 17 .79 .42

Sig (2 tailed)

.006**

.83

.26

.40

1.00

.44

.15

d

.50

.05

.03

.19

.00

.20

.32

1 vs2

2vs3

1.83

.84

20

20

.08

.41

.30

.04

HCQ SCBT

ECBT l v s 2 1.31 17 .21 .19

2vs3 1.36 17 .19 .22

WLC l v s 2 2.97 17 .79 .42





Questionnaire; *p < .05, ** p < .01, ***p < .001

130

Table 22

Paired T-Tests for Each Subscale on the WI, SHAI, and MS


Treatments Times t df Sig (2 tailed) d

WI - SS SCBT 1 vs 2 2.65 20 .02* .70

2 vs 3 1.71 20 .10 .20

ECBT 1 vs 2 2.76 17 .01* .53

2 vs 3 1.84 17 .08 .29

WLC 1 vs 2 .68 17 .51 .20

WI - DF SCBT 1 vs 2 5.75 20 .0001*** 1.42

2 vs 3 .24 17 .82 .05

ECBT 1 vs 2 3.12 17 .006** .82

2 vs 3 2.12 17 .05* .37

WLC 1 vs 2 .70 17 .50 .21

SHAI - NC SCBT 1 vs 2 2.46 20 .02* .47

2 vs 3 .11 20 .92 .03

ECBT 1 vs 2 1.35 17 .20 .31

2 vs 3 1.55 17 .14 .28

WLC 1 vs 2 .18 17 .86 .03

IAS - Fear SCBT 1 vs 2 1.15 20 .26 .21

2 vs 3 .77 20 .45 .12

131

Table 22

Paired T-Tests for Each Subscale on the WI, SHAI, and IAS



W I - S S SCBT 1 vs2 2^65 20 !(J2* ?70~

2vs3 1.71 20 .10 .20

ECBT l v s 2 2.76 17 .01* .53

2vs3 1.84 17 .08 .29

WLC l v s 2 .68 17 .51 .20

W I - D F SCBT l v s 2 5.75 20 .0001*** 1.42

2vs3 .24 17 .82 .05

ECBT l v s 2 3.12 17 .006** .82

2vs3 2.12 17 .05* .37

WLC l v s 2 .70 17 .50 .21

SHAI-NC SCBT 1 vs 2 2.46 20 .02* .47

2vs3 .11 20 .92 .03

ECBT l v s 2 1.35 17 .20 .31

2vs3 1.55 17 .14 .28

WLC l v s 2 .18 17 .86 .03

IAS-Fear SCBT l v s 2 1.15 20 .26 .21

2vs3 .77 20 .45 .12

131



IAS - Fear ECBT 1 vs 2 1.65 17 .67 .10

2 vs 3 .44 17 .67 .20

WLC 1 vs 2 -1.22 17 .24 .24

IAS - Eff SCBT 1 vs 2 2.84 20 .01* .43

2 vs 3 .43 20 .67 .06

ECBT 1 vs 2 .12 17 .91 .02

2 vs 3 2.24 17 .04* .27

WLC 1 vs 2 1.07 17 .29 .18

IAS - Exp SCBT 1 vs 2 .03 20 .98 .00

2 vs 3 -.03 20 .98 .09

ECBT 1 vs 2 2.12 17 .22 .39

2 vs 3 1.55 17 .04* .30

WLC 1 vs 2 1.47 17 .16 .16

IAS - Con SCBT 1 vs 2 1.74 20 .10 .32

2 vs 3 .62 20 .54 .01

ECBT 1 vs 2 1.28 17 .22 .23

2 vs 3 1.72 17 .10 .23

WLC 1 vs 2 .77 17 .45 .38


Behavioural Therapy; WLC = Wait-List Control; WI - SS = Whiteley Index - Somatic

132



IAS - Fear ECBT 1 vs 2 L65 17 67 I(F

2vs3 .44 17 .67 .20

WLC

IAS - Eff SCBT

ECBT

1 vs2

1 vs2

2vs3

1 vs2

2vs3

1 vs2

1 vs2

2vs3

-1.22

2.84

.43

.12

2.24

1.07

.03

-.03

17

20

20

17

17

17

20

20

.24

.01*

.67

.91

.04*

.29

.98

.98

.24

.43

.06

.02

.27

.18

.00

.09

WLC

IAS - Exp SCBT

ECBT l v s 2 2.12 17 .22 .39

2vs3 1.55 17 .04* .30

WLC l v s 2 1.47 17 .16 .16

IAS-Con SCBT l v s 2 1.74 20 .10 .32

2 v s 3 .62 20 .54 .01

ECBT l v s 2 1.28 17 .22 .23

2vs3 1.72 17 .10 .23

WLC l v s 2 .77 17 .45 .38


Behavioural Therapy; WLC = Wait-List Control; WI - SS = Whiteley Index - Somatic

132

Symptoms/Bodily Preoccupation; WI — DF = Whiteley Index — Disease Fear/Phobia;

SHAI — NC = Short Health Anxiety Inventory Negative Consequences; IAS — Fear =

Illness Attitudes Scale — Fear of Illness and Pain; IAS — Eff = Illness Attitudes Scale —

Symptom Effects; IAS — Exp = Illness Attitudes Scale — Treatment Experience; IAS —

Con = Illness Attitudes Scale — Disease Conviction; * p < .05, ** p < .01, *** p < .001

133

Symptoms/Bodily Preoccupation; WI - DF = Whiteley Index - Disease Fear/Phobia;

SHAI - NC = Short Health Anxiety Inventory — Negative Consequences; IAS - Fear =

Illness Attitudes Scale - Fear of Illness and Pain; IAS - Eff = Illness Attitudes Scale -

Symptom Effects; IAS - Exp = Illness Attitudes Scale - Treatment Experience; IAS -

Con = Illness Attitudes Scale - Disease Conviction; * p < .05, ** p < .01, *** p < .001

133

Table 23

Paired T-Test for Each Secondary Outcome Measure



ASI SCBT 1 vs 2 1.94 20 .07 .32

2 vs 3 .65 20 .52 .10

ECBT 1 vs 2 2.19 17 .04* .40

2 vs 3 1.87 17 .08 .37

WLC 1 vs 2 .38 17 .71 .09

STAI-S SCBT 1 vs 2 2.68 20 .01* .53

2 vs 3 -2.18 20 .04* .42

ECBT 1 vs 2 .80 17 .43 .21

2 vs 3 .97 17 .35 .26

WLC 1 vs 2 1.20 17 .25 .29

STAI-T SCBT 1 vs 2 2.62 20 .02* .37

2 vs 3 -.13 20 .90 .12

ECBT 1 vs 2 .70 17 .49 .13

2 vs 3 1.27 17 .22 .26

WLC 1 vs 2 1.38 17 .19 .18

GDS SCBT 1 vs 2 2.56 20 .02* .39

2 vs 3 .02 20 .99 .00

ECBT 1 vs 2 2.60 17 .02* .57

134

Table 23

Paired T-Testfor Each Secondary Outcome Measure


ASI

Treatments Times Df

SCBT l v s 2 1.94

2 vs 3 .65

20

20

Sig (2 tailed) d

.07

.52

.32

.10

STAI-S

STAI-T

GDS

ECBT

WLC

SCBT

ECBT

WLC

SCBT

ECBT

WLC

SCBT

ECBT

l v s 2

2vs3

1 vs2

1 vs2

2vs3

1 vs2

2vs3

1 vs2

1 vs2

2vs3

1 vs2

2vs3

1 vs2

1 vs2

2vs3

1 vs2

2.19

1.87

.38

2.68

-2.18

.80

.97

1.20

2.62

-.13

.70

1.27

1.38

2.56

.02

2.60

17

17

17

20

20

17

17

17

20

20

17

17

17

20

20

17

.04*

.08

.71

.01*

.04*

.43

.35

.25

.02*

.90

.49

.22

.19

.02*

.99

.02*

.40

.37

.09

.53

.42

.21

.26

.29

.37

.12

.13

.26

.18

.39

.00

.57

134



GDS ECBT 2 vs 3 .37 17 .72 .06

WLC 1 vs 2 1.07 17 .30 .18

GPM SCBT 1 vs 2 .52 20 .61 .07

2 vs 3 -.81 20 .43 .06

ECBT 1 vs 2 .64 17 .53 .21

2 vs 3 1.25 17 .23 .16

WLC 1 vs 2 -1.42 17 .18 .15

SF-12-PCS SCBT 1 vs 2 -2.20 20 .04* .22

2 vs 3 2.24 20 .04* .21

ECBT 1 vs 2 -.69 17 .50 .11

2 vs 3 -.90 17 .38 .10

WLC 1 vs 2 3.04 17 .007** .29

SF-12-MCS SCBT 1 vs 2 -2.98 20 .007** .38

2 vs 3 .71 20 .49 .13

ECBT 1 vs 2 -1.65 17 .12 .37

2 vs 3 -.84 17 .41 .17

WLC 1 vs 2 -.77 17 .45 .09




135

Measure Comparisons /-test


GDS ECBT 2vs3 37 17 J 2 ~M

WLC l v s 2 1.07 17 .30 .18

GPM SCBT l v s 2 .52 20

2vs3 -.81 20

ECBT l v s 2 .64 17

2vs3 1.25 17

WLC l v s 2 -1.42 17

SF-12-PCS SCBT l v s 2 -2.20 20

2 vs 3 2.24 20

ECBT l v s 2 -.69 17

2vs3 -.90 17

WLC l v s 2 3.04 17

SF-12-MCS SCBT 1 vs 2 -2.98 20

2vs3 .71 20

ECBT l v s 2 -1.65 17

2 v s 3 -.84 17

WLC l v s 2 -.77 17




.61

.43

.53

.23

.18

.04*

.04*

.50

.38

.007**

.007**

.49

.12

.41

.45

.07

.06

.21

.16

.15

.22

.21

.11

.10

.29

.38

.13

.37

.17

.09

135

— Trait Scale; GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; SF-12-

PCS = Short-Form — 12 — Physical Summary Score; and MCS = Short-Form — 12 —

Mental Summary Score; * p < .05, ** p < .01, *** p < .001

136


PCS = Short-Form - 12 - Physical Summary Score; and MCS = Short-Form - 12 -

Mental Summary Score; * p < .05, ** p < .01, *** p < .001

136


.03), SSI (p = .006), ASI (p = .04), GDS (p = .02), WI-Somatic Symptoms/Bodily

Preoccupation (p = .01) and WI-Disease Fear/Phobia (p = .04); and from post-treatment

to follow-up on the IAS (p = .02), WI-Disease Fear/Phobia (p = .02), IAS-Symptom

Effects (p = .04), and IAS-Treatment Experience (p = .04). There were no significant

improvements evidenced on any of the DVs for the WLC group from pre-treatment to

post-treatment, which was on the SF-12-PCS (p = .007).

The change demonstrated by the SCBT and ECBT participants was not always

significantly greater than the change demonstrated by participants in WLC group as

illustrated in the previous mixed factorial repeated measures ANCOVAs. However, the

results suggest that improvements did occur in both the SCBT and ECBT groups after

treatment. Further, the changes appeared to have been maintained in both treatment

groups and improvement continued in the ECBT group on some measures.

3.1.5.2 Clinically Significant Change

Clinically significant change has been defined by Jacobson and Truax (1991) as

"the extent to which therapy moves someone outside the range of the dysfunctional

population or within the range of the functional population" (p. 12). Jacobson and Truax

(1991) indicated that one approach of identifying clinically significant change is to

determine whether the post-treatment score falls outside two standard deviations of the

mean of the population being examined. In the present study, Jacobson and Truax's

(1991) definition was used with WI scores from pre-treatment to post-treatment. The WI

was chosen to assess clinically significant change because it was a primary outcome

137


.03), SSI (p = .006), ASI (p = .04), GDS (p = .02), Wl-Somatic Symptoms/Bodily

Preoccupation (p = .01) and WI-Disease Fear/Phobia (p = .04); and from post-treatment

to follow-up on the IAS (p = .02), WI-Disease Fear/Phobia (p = .02), IAS-Symptom

Effects (p = .04), and IAS-Treatment Experience (p = .04). There were no significant

improvements evidenced on any of the DVs for the WLC group from pre-treatment to

post-treatment, which was on the SF-12-PCS (p = .007).

The change demonstrated by the SCBT and ECBT participants was not always

significantly greater than the change demonstrated by participants in WLC group as

illustrated in the previous mixed factorial repeated measures ANCOVAs. However, the

results suggest that improvements did occur in both the SCBT and ECBT groups after

treatment. Further, the changes appeared to have been maintained in both treatment

groups and improvement continued in the ECBT group on some measures.

3.1.5.2 Clinically Significant Change

Clinically significant change has been defined by Jacobson and Truax (1991) as

"the extent to which therapy moves someone outside the range of the dysfunctional

population or within the range of the functional population" (p. 12). Jacobson and Truax

(1991) indicated that one approach of identifying clinically significant change is to

determine whether the post-treatment score falls outside two standard deviations of the

mean of the population being examined. In the present study, Jacobson and Truax's

(1991) definition was used with WI scores from pre-treatment to post-treatment. The WI

was chosen to assess clinically significant change because it was a primary outcome

137

measure, and the WI scores were integral in determining eligibility for participation.

Figure 8 indicates the proportion of participants in each treatment condition who

demonstrated clinically significant change according to the definition provided by

Jacobson and Truax (1991). Chi-square analyses using Fisher's Exact Test showed a

greater proportion of participants demonstrated clinically significant change in the SCBT

condition compared to the WLC condition, x2 (1, 39) — 13.37, p < .0001, and the ECBT

condition compared to the WLC condition, x2 (1, 39) = '7.26,p = .02. No difference was

found between the SCBT and EBCT conditions, x2 (1, 39) = 1.19,p = .34.

The proportion of individuals who no longer met criteria for being categorized as

having high health anxiety was also of interest as an indicator of the clinical significance

of change produced by each treatment. This method of assessing clinically significant

change has been utilized in prior research (e.g., Openshaw, Waller, & Sperlinger, 2004).

Figure 9 shows the proportion of participants in each treatment group with a WI score

below eight (the cut-off for entry into the study) at post-treatment and follow-up,

respectively. Chi-square analyses using Fisher's Exact Test showed a greater proportion

of participants demonstrated clinically significant change in the SCBT condition

compared to the WLC condition, x2(1, 39) = 16.52,p < .0001, and the ECBT condition

compared to the WLC condition, x,2(1, 39) = 11.69, p = .002. No difference was found

between the SCBT and EBCT conditions, x2(1, 39) = .43,p = .72.

138

measure, and the WI scores were integral in determining eligibility for participation.

Figure 8 indicates the proportion of participants in each treatment condition who

demonstrated clinically significant change according to the definition provided by

Jacobson and Truax (1991). Chi-square analyses using Fisher's Exact Test showed a

greater proportion of participants demonstrated clinically significant change in the SCBT

condition compared to the WLC condition, x2 (1, 39) = 13.37,/* < .0001, and the ECBT

condition compared to the WLC condition, x2 (1, 39) = 7.26,p = .02. No difference was

found between the SCBT and EBCT conditions, %2(l,39)=lA9,p = .34.

The proportion of individuals who no longer met criteria for being categorized as

having high health anxiety was also of interest as an indicator of the clinical significance

of change produced by each treatment. This method of assessing clinically significant

change has been utilized in prior research (e.g., Openshaw, Waller, & Sperlinger, 2004).

Figure 9 shows the proportion of participants in each treatment group with a WI score

below eight (the cut-off for entry into the study) at post-treatment and follow-up,

respectively. Chi-square analyses using Fisher's Exact Test showed a greater proportion

of participants demonstrated clinically significant change in the SCBT condition

compared to the WLC condition, x2(l, 39) = 16.52,/? < .0001, and the ECBT condition

compared to the WLC condition, x2(l, 39) = 11.69, p = .002. No difference was found

between the SCBT and EBCT conditions, x2(l, 39) = .43,p = .72.

138

SCBT ECBT WLC

Figure 8. Proportion of participants in each treatment condition who demonstrated

clinically significant change, according to Jacobson and Truax's (1992) definition, on the

WI. (SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced Cognitive

Behavioural Therapy; WLC = Wait-List Control). Original in Colour.

139

SCBT ECBT WLC

Figure 8. Proportion of participants in each treatment condition who demonstrated

clinically significant change, according to Jacobson and Truax's (1992) definition, on the

WI. (SCBT = Standard Cognitive Behavioural Therapy; ECBT = Enhanced Cognitive

Behavioural Therapy; WLC = Wait-List Control). Original in Colour.

139

E< 8

II1= > 8

SCBT ECBT WLC

Figure 9. Proportion of participants in each treatment condition who had WI scores

below 8 at post-treatment. (SCBT = Standard Cognitive Behavioural Therapy; ECBT =


Colour.

140

i < 8

l = > 8

SCBT ECBT WLC

Figure 9. Proportion of participants in each treatment condition who had WI scores

below 8 at post-treatment. (SCBT = Standard Cognitive Behavioural Therapy; ECBT


Colour.

140

3.1.6 Supplementary Analyses

3.1.6.1 Relationship Between Health Anxiety and the Therapeutic Relationship and

Motivation for Psychotherapy at Post-Treatment

Pearson correlation coefficients were calculated to evaluate the relationships

between the therapeutic alliance and motivation for psychotherapy and change in scores

from pre-treatment to post-treatment on the health anxiety measures in both of the SCBT

and ECBT groups. More specifically, the relationships between both the WAI and NML-

2 subscales scores at Session 6 and the WI, SHAI, and IAS change scores from pre-

treatment to post-treatment (change score was computed by calculating the difference in

score from pre-treatment to post-treatment) were examined. These results are presented

in Table 23 and 24. In the SCBT groups, Doubt as measured by the NML-2 was found to

be moderately negatively correlated with health anxiety as measured by the WI. In the

ECBT group, Distress as measured by the NML-2 was found to be moderately negatively

correlated with health anxiety as measured by the WI. The results suggest that among

participants treated with SCBT, lower levels of Doubt (i.e., doubt about the investment in

treatment, the treatment itself, and the possibility of gaining from it) at Session 6 were

related to greater improvements in health anxiety as measured by the WI at post-

treatment. In the ECBT group, lower levels of Distress (i.e., pressure by others and level

of distress) at Session 6 were related to greater improvements in health anxiety as

measured by the WI at post-treatment.

141

3.1.6 Supplementary Analyses

3.1.6.1 Relationship Between Health Anxiety and the Therapeutic Relationship and

Motivation for Psychotherapy at Post-Treatment

Pearson correlation coefficients were calculated to evaluate the relationships

between the therapeutic alliance and motivation for psychotherapy and change in scores

from pre-treatment to post-treatment on the health anxiety measures in both of the SCBT

and ECBT groups. More specifically, the relationships between both the WAI and NML-

2 subscales scores at Session 6 and the WI, SHAI, and IAS change scores from pre-

treatment to post-treatment (change score was computed by calculating the difference in

score from pre-treatment to post-treatment) were examined. These results are presented

in Table 23 and 24. In the SCBT groups, Doubt as measured by the NML-2 was found to

be moderately negatively correlated with health anxiety as measured by the WI. In the

ECBT group, Distress as measured by the NML-2 was found to be moderately negatively

correlated with health anxiety as measured by the WI. The results suggest that among

participants treated with SCBT, lower levels of Doubt (i.e., doubt about the investment in

treatment, the treatment itself, and the possibility of gaining from it) at Session 6 were

related to greater improvements in health anxiety as measured by the WI at post-

treatment. In the ECBT group, lower levels of Distress (i.e., pressure by others and level

of distress) at Session 6 were related to greater improvements in health anxiety as

measured by the WI at post-treatment.

141

Table 24

Correlations Between the WAI and NML-2 and the Health Anxiety Measures Change Scores in the SCBT Group

WI SHAI IAS WAI-T WAI-B WAI- G NML-2-P NML-2-Di NML-2-Do

WI .28 .16 .12 .13 .19 .23 -.20 -.61**

SHAI .79*** .12 .13 .19 -.01 -.23 -.30

IAS -.20 -.16 -.12 -.21 -.03 -.01

WAI-T .90*** .97*** .35 -.50* -.78***

WAI-B .85*** .23 -.33 -.65**

WAI-G .30 -.54* _.77***

NML-2-P .09 -.39

NML-2-Di .46*

NML-2-Do

Note. WI = Whiteley Index; SHAI = Short Health Anxiety Inventory; IAS = Illness Attitudes Scale; WAI-T = Working

Alliance Inventory - Tasks Subscale; WAI-B = Working Alliance Inventory - Bond Subscale; WAI-G = Working Alliance

Inventory - Goals Subscale; NML-2 - P = Nijmegen Motivation List-2 - Preparedness Subscale; NML-2 - Di = Nijmegen

142

Table 24

Correlations Between the WAI and NML-2 and the Health Anxiety Measures Change Scores in the SCBT Group

WI SHAI IAS WAI-T WAI-B WAI-G NML-2-P NML-2-Di NML-2-Do

WI — .28 .16 .12 .13 .19 .23 -.20 -.61**

SHAI - — .79*** .12 .13 .19 -.01 -.23 -.30

IAS - — -.20 -.16 -.12 -.21 -.03 -.01

WAI-T .90*** .97*** .35 .50* .73***

WAI-B - — .85*** .23 -.33 -.65**

WAI-G -— .30 -.54* ..77***

NML-2-P - — .09 -.39

NML-2-Di -— .46*

NML-2-Do




142

Motivation List-2 — Distress Subscale; NML-2 — Do = Nijmegen Motivation List-2 — Doubt Subscale; * p < .05, ** p < .01,

*** p < .001

143

Motivation List-2 - Distress Subscale; NML-2 - Do = Nijmegen Motivation List-2 - Doubt Subscale; * p < .05, ** p < .01,

***/?<.001

Table 25

Correlations Between the WAI and NML-2 and the Health Anxiety Measures Change Scores in the ECBT Group

WI SHAI IAS WAI-T WAI-B WAI- G NML-2-P NML-2-Di NML-2-Do

WI .51* .31 -.003 -.04 .01 -.17 -.51* -.37

SHAI .79*** -.29 -.33 -.25 -.32 -.05 -.003

IAS .22 .08 .17 -.28 -.29 -.15

WAI-T .91*** .93*** .10 -.13 -.38

WAI-B .95*** .16 .16 -.37

WAI-G .13 .13 -.36

NML-2-P -.16 .10

NML-2-Di .55*

NML-2-Do




144

Table 25

Correlations Between the WAI and NML-2 and the Health Anxiety Measures Change Scores in the ECBT Group

WI SHAI IAS WAI-T WAI-B WAI-G NML-2-P NML-2-Di NML-2-Do

WI — .51* .31 -.003 -.04 .01 -.17 -.51* -.37

SHAI .79*** -.29 -.33 -.25 -.32 -.05 -.003

IAS - — .22 .08 .17 -.28 -.29 -.15

WAI-T - — .91*** .93*** .10 -.13 -.38

WAI-B - — .95*** .16 .16 -.37

WAI-G — - .13 .13 -.36

NML-2-P - — -.16 .10

NML-2-Di -— .55*

NML-2-Do




144

Motivation List-2 — Distress Subscale; NML-2 — Do = Nijmegen Motivation List-2 — Doubt Subscale; * p < .05, ** p < .01,

*** p < .001

145

Motivation List-2 - Distress Subscale; NML-2 - Do = Nijmegen Motivation List-2 - Doubt Subscale; * p < .05, ** p < .01,

***/?<.001

3.1.6.2 Analysis of Change in the WLC Group

Data were collected from the WLC group on three occasions (Time 1 — baseline;

Time 2 — six weeks post-baseline; Time 3 — post-treatment with ECBT). A total of 11

participants completed questionnaires at all three time points. The majority of

participants were female (90.9%), and the mean age was 67.73 (SD = 7.35) years. The

majority of participants were also married or common-law (54.5%) and had completed

high school or above (54.5%). These participants had an average of 2.45 (SD = 1.86)

health conditions. The most common health conditions cited were arthritis (63.6%), high

blood pressure (54.5%), and heart disease (27.7%).

We decided to conduct one-way repeated measures ANOVAs on all primary and

secondary outcome measures with the 11 participants who underwent the treatment and

completed measures at all three time points as a way to examine further the effects of

CBT with older adults with health anxiety. All WLC participants were treated with

ECBT after the six week waiting period. Means and standard deviations on all measures

appear in Tables 25, 26, and 27.

The results from the one-way repeated measures ANOVAs assessing change in

each primary outcome measure, across all three time points are shown in Table 26.

These analyses revealed significant differences on scores on the WI (p < .0001) and the

SHAI (p = .003). On the WI, pairwise comparisons indicated that scores at Time 3 were

significantly lower than scores at Time 1 (p = .002) and at Time 2 (p = .03). On the

SHAI, pairwise comparisons indicated that scores at Time 3 were significantly lower than

scores at Time 1 (p = .01).

146

3.1.6.2 Analysis of Change in the WLC Group

Data were collected from the WLC group on three occasions (Time 1 - baseline;

Time 2 - six weeks post-baseline; Time 3 - post-treatment with ECBT). A total of 11

participants completed questionnaires at all three time points. The majority of

participants were female (90.9%), and the mean age was 67.73 (SD = 7.35) years. The

majority of participants were also married or common-law (54.5%) and had completed

high school or above (54.5%). These participants had an average of 2.45 (SD = 1.86)

health conditions. The most common health conditions cited were arthritis (63.6%), high

blood pressure (54.5%), and heart disease (27.7%).

We decided to conduct one-way repeated measures ANOVAs on all primary and

secondary outcome measures with the 11 participants who underwent the treatment and

completed measures at all three time points as a way to examine further the effects of

CBT with older adults with health anxiety. All WLC participants were treated with

ECBT after the six week waiting period. Means and standard deviations on all measures

appear in Tables 25, 26, and 27.


each primary outcome measure, across all three time points are shown in Table 26.

These analyses revealed significant differences on scores on the WI (p < .0001) and the

SHAI (p = .003). On the WI, pairwise comparisons indicated that scores at Time 3 were

significantly lower than scores at Time 1 (p = .002) and at Time 2 (p = .03). On the

SHAI, pairwise comparisons indicated that scores at Time 3 were significantly lower than

scores at Time 1 (p = .01).

146

Table 26

WLC Group Analyses at Time 1, 2, and 3 for the Primary Outcome Measures

Mean (SD) F(2,20) p T12 Time 1- Time 2 P Time 1 - Time 3 p Time 2 - Time 3 p

WI

Time 1 9.18 (1.67) 12.47 .0001 .56 .64 (9.18-8.55) 1.00 4.29 (9.18-4.90) .002 3.65 (8.55-4.90) .03

Time 2 8.55 (1.63)

Time 3 4.90 (2.52)

SHAI

Time 1 16.82 (4.62) 7.82 .003 .44 1.00 (16.82-15.82) 1.00 4.73 (16.82-12.09) .01 3.73 (15.82-12.09) .06

Time 2 15.82 (3.92)

Time 3 12.09 (4.69)

IAS

Time 1 50.64 (8.37) 1.97 .17 .16

Time 2 49.83 (10.11)

Time 3 45.64 (10.98)

SSI

Time 1 29.87 (6.56) 1.56 2.4 .14

147

Table 26

WLC Group Analyses at Time I, 2, and 3 for the Primary Outcome Measures

Mean (SO) F(2,20) p TT2 Time 1-Time 2 P Time 1-Time 3 p Time 2-Time 3 p

WI

Timel 9.18(1.67) 12.47 .0001 .56 .64(9.18-8.55) 1.00 4.29(9.18-4.90) .002 3.65(8.55-4.90) .03

Time 2 8.55(1.63)

Time 3 4.90 (2.52)

SHAI

Timel 16.82(4.62) 7.82 .003 .44 1.00(16.82-15.82) 1.00 4.73(16.82-12.09) .01 3.73(15.82-12.09) .06

Time 2 15.82(3.92)

Time 3 12.09 (4.69)

IAS

Timel 50.64(8.37) 1.97 .17 .16

Time 2 49.83(10.11)

Time 3 45.64(10.98)

SSI

Timel 29.87(6.56) 1.56 2.4 .14

147

Time 2

Time 3

SSAS

Mean (SD) F(2,20) p n2 Time 1— Time 2 P Time 1— Time 3 p Time 2 — Time 3

28.27 (5.71)

28.00 (5.42)

Time 1 28.00 (5.90) .97 .40 .09

Time 2 27.05 (4.90)

Time 3 26.43 (4.79)

HCQ

Time 1 28.40 (7.30) .70 .51 .07

Time 2 27.55 (8.54)

Time 3 26.64 (7.34)

148

Mean (SD) F(2,20) p y\2 Time 1 - Time 2 P Time 1 - Time 3 p Time 2 - Time 3 p

Time 2 28.27 (5.71)

Time 3 28.00 (5.42)

SSAS

Timel 28.00(5.90) .97 .40 .09

Time 2 27.05 (4.90)

Time 3 26.43 (4.79)

HCQ

Timel 28.40(7.30) .70 .51 .07

Time 2 27.55 (8.54)

Time 3 26.64 (7.34)

148

Table 27

WLC Group Analyses at Time 1, 2, and 3 for the Secondary Outcome Measures

Mean (SD) F(2,20) p n2 Time 1— Time 2 P Time 1— Time 3 p Time 2 — Time 3 p

ASI

Time 1 27.33 (11.33) 2.92 .10 .23

Time 2 27.60 (11.42)

Time 3 23.82 (8.34)

STAI-S

Time 1 45.08 (10.55) 9.77 .001 .49 8.68 (45.08-36.40) .02 10.08(45.08-35.00) .01 1.40 (36.40-35.00) 1.00

Time 2 36.40 (9.78)

Time 3 35.00 (8.12)

STAI-T

Time 1 45.42 (8.28) 3.07 .07 .24

Time 2 42.11 (7.81)

Time 3 42.27 (8.72)

GDS

Time 1 12.43 (5.48) 1.35 .28 .12

149

Table 27

WLC Group Analyses at Time I, 2, and 3 for the Secondary Outcome Measures

Mean (SD) F(2,20) p rfi Time 1 - Time 2 P Time 1 - Time 3 p Time 2 - Time 3 p

ASI

Timel 27.33(11.33) 2.92 .10 .23

Time 2 27.60(11.42)

Time 3 23.82 (8.34)

STAI-S

Timel 45.08(10.55) 9.77 .001 .49 8.68(45.08-36.40) .02 10.08(45.08-35.00) .01 1.40(36.40-35.00) 1.00

Time 2 36.40 (9.78)

Time 3 35.00(8.12)

STAI-T

Timel 45.42(8.28) 3.07 .07 .24

Time 2 42.11(7.81)

Time 3 42.27 (8.72)

GDS

Timel 12.43(5.48) 1.35 .28 .12

149

Time 2

Time 3

GPM

Mean (SD) F(2,20) p ri2 Time 1— Time 2 P Time 1— Time 3 p Time 2 — Time 3 P

10.77 (5.48)

10.48 (4.90)

Time 1 19.71 (12.52) .52 .60 .05

Time 2 21.01 (10.10)

Time 3 20.91 (12.58)

PCS

Time 1 42.83 (11.96) .70 .51 .07

Time 2 40.59 (12.21)

Time 3 42.70 (12.25) 1.56 .23 .14

MCS

Time 1 42.24 (10.92) 1.54 .24 .13

Time 2 45.41 (11.09)

Time 3 45.16 (7.72)

Note. ASI = Anxiety Sensitivity Index; STAI-S = State Trait Anxiety Inventory — State Scale; STAI-T = State Trait Anxiety Inventory — Trait

Scale; GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; PCS = Short-Form — 12 — Physical Summary Score; and MCS =

Short-Form — 12 — Mental Summary Score; * p < .05, ** p < .01, *** p < .001

150

Mean (SD) F(2,20) p r|2 Time 1 - Time 2 P Time 1 - Time 3 p Time 2 - Time 3 p

Time 2 10.77 (5.48)

Time 3 10.48 (4.90)

GPM

Timel 19.71(12.52) .52 .60 .05

Time 2 21.01(10.10)

Time 3 20.91(12.58)

PCS

Timel 42.83(11.96) .70 .51 .07

Time 2 40.59(12.21)

Time 3 42.70(12.25) 1.56 .23 .14

MCS

Timel 42.24(10.92) 1.54 .24 .13

Time 2 45.41(11.09)

Time 3 45.16(7.72)

State Scale; STAI-T = State Trait Anxiety Inventory - Trait

Short-Form - 12 - Physical Summary Score; and MCS =

Note. ASI = Anxiety Sensitivity Index; STAI-S = State Trait Anxiety Inventory

Scale; GDS = Geriatric Depression Scale; GPM = Geriatric Pain Measure; PCS

Short-Form - 12 - Mental Summary Score; *p< .05, ** p < .01, *** p< .001

150

Table 28

WLC Group Analyses at Time 1, 2, and 3 for the WI and SHAT Subscales

Mean (SD) F(2,20) p 1-12 Time 1— Time 2 P Time 1 — Time 3 p Time 2 — Time 3 p

WI-SS

Time 1 2.00 (1.00) 7.04 .01 .61 0.00 (2.00-2.00) 1.00 1.06 (2.00-.94) .02 1.06 (2.00-.94) .02

Time 2 2.00 (.77)

Time 3 .94 (.92)

WI-DF

Time 1 2.82 (.40) 8.18 .009 .65 .36 (2.82-1.48) .11 1.34 (2.82-1.48) .007 .97 (2.45-1.48) .05

Time 2 2.45 (.69)

Time 3 1.48 (1.21)

SHAI-

NC

Time 1 3.27 (2.41) 2.10 .18 .32

Time 2 3.37 (2.33)

Time 3 2.58 (1.54)

151

Table 28

WLC Group Analyses at Time I, 2, and 3 for the WI and SHAI Subscales

Mean (SD) F(2,20) p TJ2 Time 1 - Time 2 P Time 1 - Time 3 p Time 2 - Time 3

WI-SS

Timel 2.00(1.00) 7.04 .01 .61 0.00(2.00-2.00) 1.00 1.06 (2.00-.94) .02 1.06 (2.00-.94) .02

Time 2 2.00 (.77)

Time 3 .94 (.92)

WI-DF

Timel 2.82 (.40) 8.18 .009 .65 .36(2.82-1.48) .11 1.34(2.82-1.48) .007 .97(2.45-1.48) .05

Time 2 2.45 (.69)

Time 3 1.48(1.21)

SHAI-

NC

Timel 3.27(2.41) 2.10 .18 .32

Time 2 3.37(2.33)

Time 3 2.58(1.54)

151

Mean (SD) F(2,20) p 112 Time 1 — Time 2 P Time 1 — Time 3 p Time 2 — Time 3 p

IAS-

Fear

Time 1 13.30 (5.44) 2.81 .12 .41

Time 2 14.30 (6.25)

Time 3 12.00 (6.29)

IAS-Eff

Time 1 7.31 (1.90) .33 .72 .07

Time 2 7.04 (2.24)

Time 3 6.90 (2.59)

IAS-

Exp

Time 1 4.35 (2.06) .97 .42 .20

Time 2 4.75 (2.44)

Time 3 3.70 (3.50)

152

Mean (SD) F(2,20) p r\2 Time 1 - Time 2 P Time 1 - Time 3 p Time 2 - Time 3 p

Fear

Timel 13.30(5.44) 2.81 .12 .41

Time 2 14.30 (6.25)

Time 3 12.00 (6.29)

IAS-Eff

Timel 7.31(1.90) .33 .72 .07

Time 2 7.04 (2.24)

Time 3 6.90 (2.59)

IAS-

Exp

Timel 4.35(2.06) .97 .42 .20

Time 2 4.75 (2.44)

Time 3 3.70 (3.50)

152

Mean (SD) F(2,20) p Ti2 Time 1 — Time 2 P Time 1 — Time 3 p Time 2 — Time 3 p

IAS-

Con

Time 1 4.35 (2.06) .97 .42 .20

Time 2 4.75 (2.44)

Time 3 3.70 (3.50)

Note. WI — SS = Whiteley Index — Somatic Symptoms/Bodily Preoccupation; WI — DF = Whiteley Index — Disease Fear/Phobia; SHAI — NC =

Short Health Anxiety Inventory — Negative Consequences; IAS — Fear = Illness Attitudes Scale — Fear of Illness and Pain; IAS — Eff = Illness

Attitudes Scale — Symptom Effects; IAS — Exp = Illness Attitudes Scale — Treatment Experience; IAS — Con = Illness Attitudes Scale — Disease

Conviction; * p < .05, ** p < .01, *** p < .001

153

Mean (SD) F(2,20) p TI2 T i m e * ~Time 2 p T i m e * ~Time 3 P T i m e 2 _ T i m e 3 /> _ _

Con

Timel 4.35(2.06) .97 .42 .20

Time 2 4.75 (2.44)

Time 3 3.70 (3.50)

Note. WI - SS = Whiteley Index - Somatic Symptoms/Bodily Preoccupation; WI - DF = Whiteley Index - Disease Fear/Phobia; SHAI - NC =

Short Health Anxiety Inventory — Negative Consequences; IAS - Fear = Illness Attitudes Scale - Fear of Illness and Pain; IAS - Eff = Illness

Attitudes Scale - Symptom Effects; IAS - Exp = Illness Attitudes Scale - Treatment Experience; IAS - Con = Illness Attitudes Scale - Disease

Conviction; *p< .05, **p< .01, ***p< .001

153


each secondary outcome measure, across all three time points are shown in Table 26.

These analyses revealed significant differences on scores on the STAI-State (p = .001).

Pairwise comparisons indicated that scores at Time 2 were significantly lower than scores

at Time 1 (p = .02), and scores at Time 3 were significantly lower than scores at Time 1

(p = .01). There was no significant difference found between scores at Time 2 and Time

3.

One-way repeated measures ANOVAs assessing change in the WI, SHAI, and

IAS subscales across all three time points were conducted (results shown in Table 30).

These analyses revealed significant differences on scores on the WI-Somatic

Symptoms/Bodily Preoccupation (p = .01) and WI-Disease Fear/Phobia (p = .009). On

WI-Somatic Symptoms/Bodily Preoccupation, pairwise comparisons indicated that scores

at Time 3 were significantly lower than scores at Time 1 (p = .02), and scores at Time 3

were significantly lower than scores at Time 2 (p = .02). On WI-Disease Fear/Phobia,

pairwise comparisons indicated that scores at Time 3 were significantly lower than scores


(p = .05). There were no other significant differences noted.

These results suggest that in this WLC group that was administered ECBT after

the six week waiting period, ECBT was effective in significantly reducing health anxiety

as measured by the WI and the SHAI.

154


each secondary outcome measure, across all three time points are shown in Table 26.

These analyses revealed significant differences on scores on the STAI-State (p = .001).

Pairwise comparisons indicated that scores at Time 2 were significantly lower than scores


(p = .01). There was no significant difference found between scores at Time 2 and Time

3.

One-way repeated measures ANOVAs assessing change in the WI, SHAI, and

IAS subscales across all three time points were conducted (results shown in Table 30).

These analyses revealed significant differences on scores on the Wl-Somatic

Symptoms/Bodily Preoccupation (p = .01) and WI-Disease Fear/Phobia (p = .009). On

Wl-Somatic Symptoms/Bodily Preoccupation, pairwise comparisons indicated that scores

at Time 3 were significantly lower than scores at Time 1 (p = .02), and scores at Time 3

were significantly lower than scores at Time 2 (p = .02). On WI-Disease Fear/Phobia,

pairwise comparisons indicated that scores at Time 3 were significantly lower than scores


(p = .05). There were no other significant differences noted.

These results suggest that in this WLC group that was administered ECBT after

the six week waiting period, ECBT was effective in significantly reducing health anxiety

as measured by the WI and the SHAI.

154

3.1.7 Results of the Qualitative Analysis

3.1.7.1 Pre-Treatment Responses

A further purpose of the above study was to gather qualitative information about

health anxiety from the older adult participants and to examine this information in

relation to the CB model of health anxiety. From this analysis, six main themes

emerged as potential mechanisms for the development of health anxiety including

Anxiety is Genetic, Anxiety is a Learned Response, Vulnerability to Illness and Disease,

Awfulness of Illness, Inability to Cope, and Inability of Medical Care to Help. Several of

these themes also had subthemes (see Table 28 for outline of themes and sub-themes, and

Figure 10 for the model of the development of health anxiety in older adults).

Theme: Anxiety is Genetic. Some participants appeared to believe they were

naturally anxious or had been born that way. They reported that anxiety, worrying, and

nervousness was normal to them, because this had always been the case. For example,

one participant indicated that she worried about her health because "I am a natural

worrier."

Theme: Anxiety is a Learned Response. Some participants appeared to believe

that they had learned to respond with anxiety to health-related stressors. These

participants indicated they had learned to respond with anxiety through watching their

parents respond to health-related stressors. These participants appeared to learn that one

must be vigilant about one's health to avoid illness and disease and that health problems

were something to fear. For example, one participant indicated: "I worry about my health

because I observed my parents' approach to aches and pains, which was negative and to

155

3.1.7 Results of the Qualitative Analysis

3.1.7.1 Pre-Treatment Responses

A further purpose of the above study was to gather qualitative information about

health anxiety from the older adult participants and to examine this information in

relation to the CB model of health anxiety. From this analysis, six main themes

emerged as potential mechanisms for the development of health anxiety including

Anxiety is Genetic, Anxiety is a Learned Response, Vulnerability to Illness and Disease,

Awfulness of Illness, Inability to Cope, and Inability of Medical Care to Help. Several of

these themes also had subthemes (see Table 28 for outline of themes and sub-themes, and

Figure 10 for the model of the development of health anxiety in older adults).

Theme: Anxiety is Genetic. Some participants appeared to believe they were

naturally anxious or had been born that way. They reported that anxiety, worrying, and

nervousness was normal to them, because this had always been the case. For example,

one participant indicated that she worried about her health because "I am a natural

worrier."

Theme: Anxiety is a Learned Response. Some participants appeared to believe

that they had learned to respond with anxiety to health-related stressors. These

participants indicated they had learned to respond with anxiety through watching their

parents respond to health-related stressors. These participants appeared to learn that one

must be vigilant about one's health to avoid illness and disease and that health problems

were something to fear. For example, one participant indicated: "I worry about my health

because I observed my parents' approach to aches and pains, which was negative and to

155

Table 29

Themes and Sub-Themes of the Development of Health Anxiety in Seniors

Themes Sub-themes

Anxiety is Genetic

Anxiety is a Learned Response •

•

Experience with Illness

Experience with Death

Vulnerability to Illness

Awfulness of Illness •

•

•

•

Fear of Death

Fear of Pain

Fear of Disability & Dependence

Fear of Missing Out

Inability to Cope

Inability of Medical Care to Help

156

Table 29

Themes and Sub-Themes of the Development of Health Anxiety in Seniors

Themes

Anxiety is Genetic

Anxiety is a Learned Response

Vulnerability to Illness

Awfulness of Illness

Inability to Cope

Inability of Medical Care to Help

Sub-themes

• Experience with Illness

• Experience with Death

• Fear of Death

• Fear of Pain

• Fear of Disability & Dependence

• Fear of Missing Out

156

Genetics

HEALTH

ANXIETY

i Core Belief About Health &

Illness • Vulnerability to Disease • Inability to Cope • Awful Consequences • Inadequacy of

Physicians/Medical Care

Learning • Experience with

Illness • Experience with

Death

Figure 10. Model of the development of health anxiety in older adults

157

Genetics Learning

• Experience with Illness

• Experience with Death

Core Belief About Health & Illness

• Vulnerability to Disease • Inability to Cope • Awful Consequences • Inadequacy of

Physicians/Medical Care

Figure 10. Model of the development of health anxiety in older adults

157

be endured." In addition, participants appeared to believe their own experience with

illness and death contributed to their learning that health and illness should be feared.

Further analysis of the data revealed two sub-themes that illustrated the more specific

experiences that participants had with learning about illness including Experience with

Illness and Experience with Death.

Sub-theme: Experience with Illness. Many of the participants reported various

personal experiences with illness and health-related issues, such as experience with their

own personal health issues and with the health issues of family and friends, both mental

and physical. Some participants recalled noteworthy experiences with illness and health

issues beginning in childhood. For example, one participant indicated she had

experienced "unpleasant visits to doctors and hospitals. [I] became very frightened of

brick buildings and developed a fear of hospitals." Participants also reported significant

experiences with mental health issues: "I was hospitalized for anxiety and depression. I

have been treated for both over time." Finally, some participants also reported

experiencing current significant and life-changing health problems. For example, one

participant reported that "I had a stroke (trans ischemic attack) in 2000. I wasn't sure

what it was at first, but I had a great fear that something bad was going to happen to me."

Many of the older adults reported witnessing, throughout their lifetime, family

members, especially parents and friends', experiences of illness and health concerns. It

appeared that many of these participants were significantly negatively impacted by these

experiences. For example, one participant reported: "My mom and other family members

have both diabetes and heart disease. I worry about it." Other participants reported

158

be endured." In addition, participants appeared to believe their own experience with

illness and death contributed to their learning that health and illness should be feared.

Further analysis of the data revealed two sub-themes that illustrated the more specific

experiences that participants had with learning about illness including Experience with

Illness and Experience with Death.

Sub-theme: Experience with Illness. Many of the participants reported various

personal experiences with illness and health-related issues, such as experience with their

own personal health issues and with the health issues of family and friends, both mental

and physical. Some participants recalled noteworthy experiences with illness and health

issues beginning in childhood. For example, one participant indicated she had

experienced "unpleasant visits to doctors and hospitals. [I] became very frightened of

brick buildings and developed a fear of hospitals." Participants also reported significant

experiences with mental health issues: "I was hospitalized for anxiety and depression. I

have been treated for both over time." Finally, some participants also reported

experiencing current significant and life-changing health problems. For example, one

participant reported that "I had a stroke (trans ischemic attack) in 2000. I wasn't sure

what it was at first, but I had a great fear that something bad was going to happen to me."

Many of the older adults reported witnessing, throughout their lifetime, family

members, especially parents and friends', experiences of illness and health concerns. It

appeared that many of these participants were significantly negatively impacted by these

experiences. For example, one participant reported: "My mom and other family members

have both diabetes and heart disease. I worry about it." Other participants reported

158

witnessing family members with mental health issues. For example, "I have a bad family

history of suicide — father, sister, aunt, cousin."

Sub-theme: Experience with Death. Many of the participants reported personal

experiences with death that were significant and, for some, problematic. Some

participants reported their own personal close calls with death and many participants

reported having a difficult time coping with deaths of family members. These close calls

occurred in childhood for some and throughout adulthood for others. For example, one

participant reported: "At three weeks of age, I developed whooping cough and almost

died. I was a sickly child." Others reported medical emergencies that were dangerous

and life-threatening. For example, one participant indicated "I experienced a severe post-

partum haemorrhage and had to receive blood transfusions. I almost died..."

Some participants recalled witnessing the death of family members and friends

from health-related issues or complications. Many indicated these experiences had been

difficult and distressing. For example, one participant indicated that "My mother and

sister both died in their 60's from cancer. These were horrible, painful deaths." Another

participant indicated that "My father passed away at the age of 60 because of kidney

failure. There was no dialysis at the time. I've had a sister and brother die from cancer.

That was traumatic."

Theme: Vulnerability to Illness. Some participants reported they felt vulnerable to

illness and at greater risk for developing various diseases. Some participants reported

that due to poor health habits, such as smoking and not taking care of themselves, they

felt at higher risk for developing illness and disease. One participant reported that "I

159

witnessing family members with mental health issues. For example, "I have a bad family

history of suicide - father, sister, aunt, cousin."

Sub-theme: Experience with Death. Many of the participants reported personal

experiences with death that were significant and, for some, problematic. Some

participants reported their own personal close calls with death and many participants

reported having a difficult time coping with deaths of family members. These close calls

occurred in childhood for some and throughout adulthood for others. For example, one

participant reported: "At three weeks of age, I developed whooping cough and almost

died. I was a sickly child." Others reported medical emergencies that were dangerous

and life-threatening. For example, one participant indicated "I experienced a severe post

partum haemorrhage and had to receive blood transfusions. I almost died..."

Some participants recalled witnessing the death of family members and friends

from health-related issues or complications. Many indicated these experiences had been

difficult and distressing. For example, one participant indicated that "My mother and

sister both died in their 60's from cancer. These were horrible, painful deaths." Another

participant indicated that "My father passed away at the age of 60 because of kidney

failure. There was no dialysis at the time. I've had a sister and brother die from cancer.

That was traumatic."

Theme: Vulnerability to Illness. Some participants reported they felt vulnerable to

illness and at greater risk for developing various diseases. Some participants reported

that due to poor health habits, such as smoking and not taking care of themselves, they

felt at higher risk for developing illness and disease. One participant reported that "I

159

smoked a pack [of cigarettes] a day until I was 40. I keep expecting to get lung cancer."

Another participant reported "When my husband was sick...things went downhill from

there. It started with rheumatoid arthritis. When he died that was hard and that was

when I started worrying about [my own] health. I didn't take care of myself because I

was taking care of my husband."

Other participants appeared to feel that, because of their family history of health

issues, they were at increased risk for developing health-related issues. One other

participant wrote the following: "It crosses my mind that I would get cancer because my

parents both had cancer."

Theme: Awfulness of Illness. Another prominent concern among participants was

the perception that illness or disease would result in various serious negative

consequences. Many reported feeling fearful and anxious about what would accompany

the illness/disease. Further analysis of the data revealed five sub-themes that illustrated

the more specific experiences that participants had with awfulness of illness including

Fear of Death, Fear of Pain, Fear of Disability and Dependence, and Fear of Missing

Out on Life.

Sub-theme: Fear of Death. Some participants reported they were fearful that they

would die as a result of a health-related issue or disease. When asked what it was about

health that she worried about, one participant wrote: "When I get short of breath I

worry...worry that I will die. I don't think it's my time, and I got lots of things yet to do."

Another participant wrote: "[I worry] about having another stoke when my heart is

160

smoked a pack [of cigarettes] a day until I was 40. I keep expecting to get lung cancer."

Another participant reported "When my husband was sick...things went downhill from

there. It started with rheumatoid arthritis. When he died that was hard and that was

when I started worrying about [my own] health. I didn't take care of myself because I

was taking care of my husband."

Other participants appeared to feel that, because of their family history of health

issues, they were at increased risk for developing health-related issues. One other

participant wrote the following: "It crosses my mind that I would get cancer because my

parents both had cancer."

Theme: Awfulness of Illness. Another prominent concern among participants was

the perception that illness or disease would result in various serious negative

consequences. Many reported feeling fearful and anxious about what would accompany

the illness/disease. Further analysis of the data revealed five sub-themes that illustrated

the more specific experiences that participants had with awfulness of illness including

Fear of Death, Fear of Pain, Fear of Disability and Dependence, and Fear of Missing

Out on Life.

Sub-theme: Fear of Death. Some participants reported they were fearful that they

would die as a result of a health-related issue or disease. When asked what it was about

health that she worried about, one participant wrote: "When I get short of breath I

worry...worry that I will die. I don't think it's my time, and I got lots of things yet to do.v

Another participant wrote: "[I worry] about having another stoke when my heart is

160

beating fast, and the threat of another one bothers me. [I worry] that I will end up being

disabled and dead."

Sub-theme: Fear of Pain. Other participants appeared to be most fearful of the

pain that often accompanies illness and disease. One participant indicated that "As I get

older, I have more aches and pains. I am worried about how far that will go." As another

example, one participant indicated that "Arthritis and osteoporosis have the potential to

be painful so I need to manage these as well as possible."

Sub-theme: Fear of Disability and Dependence. Other participants reported a fear

of becoming disabled or dependent on others as a result of a health problem or disease.

One participant indicated: "[I am] worried about the loss of independence and how I'll

manage physically." Another participant reported that "I worry that I will end up being

disabled. I saw [my] aunt who was paralyzed from a stroke and [I have] the idea that this

could happen to me."

Sub-theme: Fear of Missing Out on Experiences. Some participants reported that

they felt that if they became ill or their health deteriorated, they would miss out on

various important life experiences or opportunities. They felt that they still had things to

accomplish, and they appeared fearful that an illness or disease would interfere with that.

Still others felt that they had only a limited amount of time left in life and they did not

want to spend those years being sick. For example, one participant indicated that "[I

worry] that the cancer is going to come back and that the Crohn's disease will come back

because this will affect things in my life. That I will end up running out of time to do all

the things that I want to do."

161

beating fast, and the threat of another one bothers me. [I worry] that I will end up being

disabled and dead."

Sub-theme: Fear of Pain. Other participants appeared to be most fearful of the

pain that often accompanies illness and disease. One participant indicated that "As I get

older, I have more aches and pains. I am worried about how far that will go." As another

example, one participant indicated that "Arthritis and osteoporosis have the potential to

be painful so I need to manage these as well as possible."

Sub-theme: Fear of Disability and Dependence. Other participants reported a fear

of becoming disabled or dependent on others as a result of a health problem or disease.

One participant indicated: "[I am] worried about the loss of independence and how I'll

manage physically." Another participant reported that "I worry that I will end up being

disabled. I saw [my] aunt who was paralyzed from a stroke and [I have] the idea that this

could happen to me."

Sub-theme: Fear of Missing Out on Experiences. Some participants reported that

they felt that if they became ill or their health deteriorated, they would miss out on

various important life experiences or opportunities. They felt that they still had things to

accomplish, and they appeared fearful that an illness or disease would interfere with that.

Still others felt that they had only a limited amount of time left in life and they did not

want to spend those years being sick. For example, one participant indicated that "[I

worry] that the cancer is going to come back and that the Crohn's disease will come back

because this will affect things in my life. That I will end up running out of time to do all

the things that I want to do."

161

Theme: Inability to Cope. Some participants reported they believed that they

would be unable to cope with illness and disease. These participants appeared to fear that

they would be unable to cope because they were alone and they did not have anyone to

help them. Others indicated they felt that after learning they had an illness or disease,

they would be emotionally unable to cope with the disease. One participant indicated

that "I am worried about getting old and my health steadily declining. I am also worried

about not being able to cope with the problems of old age and illness in myself and my

spouse." One participant indicated that "I worry about my heart, having a stroke, and

cancer. How would I cope if I was told I had a serious illness? I feel I would [have] a

serious case of depression."

Theme: Inadequacy of Medical Care. Another concern reported by participants

was the belief that the medical system and physicians would be unable to help them if

they became ill. They described having little confidence in their physician to diagnose or

treat their health-related issues. For example, one participant indicated that "Sometimes

when [I] go to the doctor, I feel like they are not listening to me or they might be missing

something. I know what's in my body, I know something's not right and they won't

check it out. Feel pretty helpless when seeing the doctor and they aren't checking

everything. Since I've had cancer, they are supposed to have a complete body check.

When the doctor says things are fine, what can you do even when you know there is

something wrong?"

162

Theme: Inability to Cope. Some participants reported they believed that they

would be unable to cope with illness and disease. These participants appeared to fear that

they would be unable to cope because they were alone and they did not have anyone to

help them. Others indicated they felt that after learning they had an illness or disease,

they would be emotionally unable to cope with the disease. One participant indicated

that "I am worried about getting old and my health steadily declining. I am also worried

about not being able to cope with the problems of old age and illness in myself and my

spouse." One participant indicated that "I worry about my heart, having a stroke, and

cancer. How would I cope if I was told I had a serious illness? I feel I would [have] a

serious case of depression."

Theme: Inadequacy of Medical Care. Another concern reported by participants

was the belief that the medical system and physicians would be unable to help them if

they became ill. They described having little confidence in their physician to diagnose or

treat their health-related issues. For example, one participant indicated that "Sometimes

when [I] go to the doctor, I feel like they are not listening to me or they might be missing

something. I know what's in my body, I know something's not right and they won't

check it out. Feel pretty helpless when seeing the doctor and they aren't checking

everything. Since I've had cancer, they are supposed to have a complete body check.

When the doctor says things are fine, what can you do even when you know there is

something wrong?"

162

3.1.7.2 Post-Treatment Responses

A model of older adult's therapy experiences was generated based on the

qualitative data analysis (see Figure 11). This model encompassed four themes that

emerged from the analysis: Essential Components of the Therapy Experience, Essential

Components of the Therapeutic Relationship, Benefits of the Therapy Experience, and

Issues with the Therapy Program (see Table 29 for outline of themes and sub-themes).

Theme: Essential Components of the Therapy Experience. Participants described

what they felt to be the most helpful and essential components of the therapy experience.

Further analysis of the data revealed five sub-themes that illustrated more specifically the

essential components of the therapy experience including Act of Talking to Someone

about Issues, Specific Self-Management Skills, Education and Information, and

Assignment of Homework

Sub-theme: Act of Talking to Someone about Issues. Many participants appeared

to feel that the act of discussing their issues with a professional was beneficial and

therapeutic. Participants indicated that having time to discuss problematic issues in their

lives with a therapist, and being given support and reassurance by the therapist was an

essential component of making the therapy a positive experience. For example, one

participant indicated that "talking to a professional was therapeutic [because I talked]

through the feelings I was having due to my health issues." Another participant, when

asked what she found most beneficial about the therapy program, wrote: "Just to be

speaking together. Simply, a way of speaking one-to-one with a professional

psychologist to release pent up concerns about mental, emotional, and physical

163

3.1.7.2 Post-Treatment Responses

A model of older adult's therapy experiences was generated based on the

qualitative data analysis (see Figure 11). This model encompassed four themes that

emerged from the analysis: Essential Components of the Therapy Experience, Essential

Components of the Therapeutic Relationship, Benefits of the Therapy Experience, and

Issues with the Therapy Program (see Table 29 for outline of themes and sub-themes).

Theme: Essential Components of the Therapy Experience. Participants described

what they felt to be the most helpful and essential components of the therapy experience.

Further analysis of the data revealed five sub-themes that illustrated more specifically the

essential components of the therapy experience including Act of Talking to Someone

about Issues, Specific Self-Management Skills, Education and Information, and

Assignment of Homework.

Sub-theme: Act of Talking to Someone about Issues. Many participants appeared

to feel that the act of discussing their issues with a professional was beneficial and

therapeutic. Participants indicated that having time to discuss problematic issues in their

lives with a therapist, and being given support and reassurance by the therapist was an

essential component of making the therapy a positive experience. For example, one

participant indicated that "talking to a professional was therapeutic [because I talked]

through the feelings I was having due to my health issues." Another participant, when

asked what she found most beneficial about the therapy program, wrote: "Just to be

speaking together. Simply, a way of speaking one-to-one with a professional

psychologist to release pent up concerns about mental, emotional, and physical

163

Essential Components of Essential Components of Therapy Program Therapeutic Relationship

Self-Management

Skills

Education & Information

Addresses Issues

Act of Talking to a

Professional

Positive Therapy Experience • Knowledge & Skill • Normalization • Time for Self-Care • Insight and Awareness • Confidence & Autonomy

Homework & Practice

Therapist Qualities

Empathic Professional Calm and relaxed Optimistic Friendly Non-judgemental Trustworthy Genuinely interested Invested in Outcome Honest and Sincere

Therapist Actions • Being present — face to face • Putting client at ease • Encouraging and reinforcing • Communicating belief in

therapy program • Instilling hope

Figure 11. Model of older adults ' experiences and perceptions of psychological treatment

for health anxiety

164

Essential Components of Therapy Program

Essential Components of Therapeutic Relationship

Act of Talking to a

Professional

Self-Management

Skills

Education & Information

Addresses Issues

Therapist Qualities

Empathic Professional Calm and relaxed Optimistic Friendly Non-judgemental Trustworthy Genuinely interested Invested in Outcome Honest and Sincere

Homework & Practice

Therapist Actions • Being present - face to face • Putting client at ease • Encouraging and reinforcing • Communicating belief in

therapy program • Instilling hope

Figure 11. Model of older adults' experiences and perceptions of psychological treatment

for health anxiety

164

Table 30

Themes and Sub-themes of Older Adults ' Experiences and Perceptions of Psychological

Treatment for Health Anxiety

Themes Sub-themes

Essential Component of Therapy

Program

• Act of Talking to a Professional

• Self-Management Skills

• Education & Information

• Homework & Practice

Essential Components of Therapeutic

Relationship

• Therapist Qualities

• Empathic

• Professional

• Calm and relaxed

• Optimistic

• Friendly

• Non-judgemental

• Trustworthy

• Genuinely interested

• Invested in Outcome

• Honest and Sincere

• Therapist Actions

• Being present — face to face

165

Table 30

Themes and Sub-themes of Older Adults' Experiences and Perceptions of Psychological

Treatment for Health Anxiety

Themes

Essential Component of Therapy

Program

Essential Components of Therapeutic

Relationship

Sub-themes

• Act of Talking to a Professional

• Self-Management Skills

• Education & Information

• Homework & Practice

• Therapist Qualities

• Empathic

• Professional

• Calm and relaxed

• Optimistic

• Friendly

• Non-judgemental

• Trustworthy

• Genuinely interested

• Invested in Outcome

• Honest and Sincere

• Therapist Actions

• Being present - face to face

165

• Putting client at ease

• Encouraging and reinforcing

• Communicating belief in therapy

program

• Instilling hope

Benefits of Therapy Experience • Knowledge & Skill

• Normalization

• Time for Self-Care

• Insight & Awareness

• Confidence & Autonomy

Issue with the Therapy Program • Did Not Adequately Address Problems

166

Benefits of Therapy Experience

Issue with the Therapy Program

• Putting client at ease

• Encouraging and reinforcing

• Communicating belief in therapy

program

• Instilling hope

• Knowledge & Skill

• Normalization

• Time for Self-Care

• Insight & Awareness

• Confidence & Autonomy

• Did Not Adequately Address Problems

166

behaviours" was helpful.

Sub-theme: Specific Self-Management Skills. Participants' experience of the

helpfulness of the various self-management techniques in decreasing anxiety and

improving well-being was a prominent theme among the responses. Most participants

reported at least one technique that they found useful but many participants listed a

number of the techniques for reducing their anxiety including relaxation techniques,

cognitive restructuring, goal setting, and distraction techniques. For example, one

participant wrote the following: "So now I can take on my health anxiety and use some of

the techniques I learned in the program — breathing exercises to calm you down and

distraction techniques"; and Coping techniques: 1) substituting new attitudes for negative

ones — new ways of looking at a situation; self-talk — rid myself of 'all or nothing'

attitude; diaphragmatic breathing for stress relief; distractions useful if unhealthy

thoughts bother me."

Sub-theme: Education and Information. Some participants reported they felt that

the provision of education and information to be an important and beneficial component

of the therapy programs. Participants indicated that education and information on

anxiety, coping, and self-management were helpful and that having written information

to review outside of therapy was a useful reminder or explanation for what had been

discussed during therapy. For example, one participant wrote "I was given information

which has helped me with my Parkinson's [disease] and the physical sensations

associated with the disease. I learned that I could deal with the anxiety and stress related

to my Parkinson's disease by doing the relaxation exercises to stay calm and found it

167

behaviours" was helpful.

Sub-theme: Specific Self-Management Skills. Participants' experience of the

helpfulness of the various self-management techniques in decreasing anxiety and

improving well-being was a prominent theme among the responses. Most participants

reported at least one technique that they found useful but many participants listed a

number of the techniques for reducing their anxiety including relaxation techniques,

cognitive restructuring, goal setting, and distraction techniques. For example, one

participant wrote the following: "So now I can take on my health anxiety and use some of

the techniques I learned in the program - breathing exercises to calm you down and

distraction techniques"; and Coping techniques: 1) substituting new attitudes for negative

ones - new ways of looking at a situation; self-talk - rid myself of 'all or nothing'

attitude; diaphragmatic breathing for stress relief; distractions useful if unhealthy

thoughts bother me."

Sub-theme: Education and Information. Some participants reported they felt that

the provision of education and information to be an important and beneficial component

of the therapy programs. Participants indicated that education and information on

anxiety, coping, and self-management were helpful and that having written information

to review outside of therapy was a useful reminder or explanation for what had been

discussed during therapy. For example, one participant wrote "I was given information

which has helped me with my Parkinson's [disease] and the physical sensations

associated with the disease. I learned that I could deal with the anxiety and stress related

to my Parkinson's disease by doing the relaxation exercises to stay calm and found it

167

helped me settle down." Another participant wrote the following: "The therapist brought

in new ideas that I had not considered before. When I have sensations of burning,

especially in the facial area, I remember to say to myself, 'This is no worse than it has

been previous, so it will ease up.' I never realized how powerful the mind is."

Sub-theme: Homework Some participants reported that they found that the

assignment of homework which resulted in having to practice the various self-

management skills to be helpful in learning how to manage their anxiety. For example,

one participant wrote that what helped motivate her to continue with the program was

"homework and going back to my list and to the handout book. Practice, practice how I

was thinking about sensations." Another participant wrote the following: "At every

session, we always discussed the methods I was using to counter stress — applied

relaxation or the diaphragmatic breathing exercise to reduce as much stress as possible.

We also discussed the rest of the techniques that I was using. As this was discussed at

every session, I understood that it was my responsibility to implement these exercises if I

wanted to change and feel better about myself and my health."

Theme: Essential Components of the Therapeutic Relationship. Most participants

indicated that they felt the therapeutic relationship had been a good one and described

positive experiences with their therapist. They also described what they felt to be the

most helpful and essential components of the therapeutic relationship. Further analysis of

the data revealed two sub-themes that illustrated more specifically the essential

components of the therapeutic relationship including Therapist Qualities and Therapist

Actions.

168

helped me settle down." Another participant wrote the following: "The therapist brought

in new ideas that I had not considered before. When I have sensations of burning,

especially in the facial area, I remember to say to myself, 'This is no worse than it has

been previous, so it will ease up.' I never realized how powerful the mind is."

Sub-theme: Homework. Some participants reported that they found that the

assignment of homework which resulted in having to practice the various self-

management skills to be helpful in learning how to manage their anxiety. For example,

one participant wrote that what helped motivate her to continue with the program was

"homework and going back to my list and to the handout book. Practice, practice how I

was thinking about sensations." Another participant wrote the following: "At every

session, we always discussed the methods I was using to counter stress - applied

relaxation or the diaphragmatic breathing exercise to reduce as much stress as possible.

We also discussed the rest of the techniques that I was using. As this was discussed at

every session, I understood that it was my responsibility to implement these exercises if I

wanted to change and feel better about myself and my health."

Theme: Essential Components of the Therapeutic Relationship. Most participants

indicated that they felt the therapeutic relationship had been a good one and described

positive experiences with their therapist. They also described what they felt to be the

most helpful and essential components of the therapeutic relationship. Further analysis of

the data revealed two sub-themes that illustrated more specifically the essential

components of the therapeutic relationship including Therapist Qualities and Therapist

Actions.

168

Sub-theme: Therapist Qualities. Most participants reported that they believed

specific therapist qualities positively impacted on the therapeutic relationship and their

level of motivation for therapy. Participants consistently indicated that the following

therapist qualities were important for fostering the therapeutic relationship and

motivation for psychotherapy: empathic; professional — knowledgeable, effective

communicator; calm and relaxed; optimistic; friendly; non-judgemental; trustworthy,

genuinely interested in the patient; invested in therapy outcome; and honest and sincere.

For example, one participant wrote "The therapist was excellent in her knowledge of

anxiety disorders and how it related to me. There was excellent communication between

us and she was very cooperative and helpful to me, and that strengthened the

relationship." When asked what she felt helped strengthen the therapeutic relationship,

another participant wrote "[The therapist] was a good listener, non-judgemental, guided

me in the right direction, she was friendly and she smiled, and she was easy to talk to."

Sub-theme: Therapist Actions. Most participants reported they believed specific

therapist actions positively impacted on the therapeutic relationship and their level of

motivation for psychotherapy. Participants consistently indicated that the following

therapist actions were important for fostering the therapeutic relationship and motivation

for therapy: being present or face-to-face, putting the client at ease, encouraging and

reinforcing, communicating belief in the therapy program, and instilling hope. For

example, one participant, when asked what helped motivate her during therapy, wrote

that "[The therapist] seemed to 'so believe' in the program and that it could help me that I

tried to participate fully." Another participant wrote "I think [my therapist] encouraged

169

Sub-theme: Therapist Qualities. Most participants reported that they believed

specific therapist qualities positively impacted on the therapeutic relationship and their

level of motivation for therapy. Participants consistently indicated that the following

therapist qualities were important for fostering the therapeutic relationship and

motivation for psychotherapy: empathic; professional - knowledgeable, effective

communicator; calm and relaxed; optimistic; friendly; non-judgemental; trustworthy,

genuinely interested in the patient; invested in therapy outcome; and honest and sincere.

For example, one participant wrote "The therapist was excellent in her knowledge of

anxiety disorders and how it related to me. There was excellent communication between

us and she was very cooperative and helpful to me, and that strengthened the

relationship." When asked what she felt helped strengthen the therapeutic relationship,

another participant wrote "[The therapist] was a good listener, non-judgemental, guided

me in the right direction, she was friendly and she smiled, and she was easy to talk to."

Sub-theme: Therapist Actions. Most participants reported they believed specific

therapist actions positively impacted on the therapeutic relationship and their level of

motivation for psychotherapy. Participants consistently indicated that the following

therapist actions were important for fostering the therapeutic relationship and motivation

for therapy: being present or face-to-face, putting the client at ease, encouraging and

reinforcing, communicating belief in the therapy program, and instilling hope. For

example, one participant, when asked what helped motivate her during therapy, wrote

that "[The therapist] seemed to 'so believe' in the program and that it could help me that I

tried to participate fully." Another participant wrote "I think [my therapist] encouraged

169

me quite a lot — I was sorry that the sessions had to end because I really felt that I

benefitted from our relationship."

Theme: Benefits of the Therapy Experience. All but two participants reported

they experienced a number of benefits from engaging in the therapy experience, and that

therapy had been worthwhile. Further analysis of the data revealed five sub-themes that

illustrated the more specific benefits that participants had with the therapy experience

including Knowledge and Skill, Normalization, Time for Self-care, Insight and

Awareness, and Confidence and Autonomy.

Sub-theme: Knowledge and Skill: Many participants reported that, during

therapy, they were able to gain knowledge and skills related to the management of health

anxiety. More specifically, many participants indicated they gained knowledge and skill

related to coping strategies, the construct of health anxiety and worry, and future

maintenance of mental health. For example, one participant wrote that "[The program

helped improve my worries about my health] by providing me with ideas on how to cope

and by educating [me] on how this (anxiety) has become an obstacle in my life and could

eventually become all consuming if not recognized and stopped." Another participant

indicated "Yes, the program did help. I realized more that health and other kinds of

worries affect what that I do and my behaviour shows it. My behaviour can influence the

amount of health anxiety I have and cope with my problems. So I now can take on my

health anxiety and use some of the techniques I learned in the program — i.e., 1) breath

exercise to calm you down, 2) distraction techniques. The techniques and strategies I

170

me quite a lot - 1 was sorry that the sessions had to end because I really felt that I

benefitted from our relationship."

Theme: Benefits of the Therapy Experience. All but two participants reported

they experienced a number of benefits from engaging in the therapy experience, and that

therapy had been worthwhile. Further analysis of the data revealed five sub-themes that

illustrated the more specific benefits that participants had with the therapy experience

including Knowledge and Skill, Normalization, Time for Self-care, Insight and

Awareness, and Confidence and Autonomy.

Sub-theme: Knowledge and Skill: Many participants reported that, during

therapy, they were able to gain knowledge and skills related to the management of health

anxiety. More specifically, many participants indicated they gained knowledge and skill

related to coping strategies, the construct of health anxiety and worry, and future

maintenance of mental health. For example, one participant wrote that "[The program

helped improve my worries about my health] by providing me with ideas on how to cope

and by educating [me] on how this (anxiety) has become an obstacle in my life and could

eventually become all consuming if not recognized and stopped." Another participant

indicated "Yes, the program did help. I realized more that health and other kinds of

worries affect what that I do and my behaviour shows it. My behaviour can influence the

amount of health anxiety I have and cope with my problems. So I now can take on my

health anxiety and use some of the techniques I learned in the program - i.e., 1) breath

exercise to calm you down, 2) distraction techniques. The techniques and strategies I

170

learn here will allow me to maintain my behaviour and replace them with ways that will

increase my well being."

Sub-theme: Normalization. Some participants indicated they felt their anxiety

issues were normalized during therapy. For example, one participant indicated that the

program helped her by "showing me that it's normal to have a few worries about my

health and how I think about them. I now recognize sensations as normal and redirect

them with good feelings." Another participant indicated that the program helped improve

his worries about his health by "becoming aware that others feel the same [as I do]."

Sub-theme: Time for Self-Care. A few participants reported they felt they were

able to give themselves some time for self-care without feeling guilty about doing so.

One participant indicated that what she found most helpful was "not feeling guilty about

doing this for myself." Another participant indicated that what she found most helpful

about the program was that she was able to "devote time to [herself] by going" to

therapy.

Sub-theme: Insight and Self-Awareness. Some participants reported they gained

insight and awareness about themselves and their anxiety issues. One participant

indicated that what she found most helpful about the program was "by educating me and

becoming more aware of my patterns, I could use the different suggestions to minimize

or eliminate my anxiety." Other participants indicated that "It made me realize how

anxiety can affect all areas of my life."

Sub-theme: Confidence and Autonomy. Many participants reported they gained

confidence that they could effectively manage their anxiety and worry and that they could

171

learn here will allow me to maintain my behaviour and replace them with ways that will

increase my well being."

Sub-theme: Normalization. Some participants indicated they felt their anxiety

issues were normalized during therapy. For example, one participant indicated that the

program helped her by "showing me that it's normal to have a few worries about my

health and how I think about them. I now recognize sensations as normal and redirect

them with good feelings." Another participant indicated that the program helped improve

his worries about his health by "becoming aware that others feel the same [as I do]."

Sub-theme: Time for Self-Care. A few participants reported they felt they were

able to give themselves some time for self-care without feeling guilty about doing so.

One participant indicated that what she found most helpful was "not feeling guilty about

doing this for myself." Another participant indicated that what she found most helpful

about the program was that she was able to "devote time to [herself] by going" to

therapy.

Sub-theme: Insight and Self-Awareness. Some participants reported they gained

insight and awareness about themselves and their anxiety issues. One participant

indicated that what she found most helpful about the program was "by educating me and

becoming more aware of my patterns, I could use the different suggestions to minimize

or eliminate my anxiety." Other participants indicated that "It made me realize how

anxiety can affect all areas of my life."

Sub-theme: Confidence and Autonomy. Many participants reported they gained

confidence that they could effectively manage their anxiety and worry and that they could

171

continue this successfully after the treatment sessions were completed. Participants also

indicated they gained hope that their anxiety and worry could decrease if they continued

to attend therapy and if they practiced the various anxiety management techniques that

were discussed during the sessions. For example, one participant indicated she felt the

program helped improve her worries about her health by "recognizing that I had the

knowledge and confidence to deal with problems." Other participants also indicated that

they felt they gained the knowledge and confidence to more effectively cope with

anxiety: "I feel more confident that I'm doing the right things to cope with anxiety." For

example, when asked if the program helped improve her worries about her health, one

participant wrote that "[It] gave me a better attitude, so I feel more positive about the

future of my health. I felt very negative and depressed about the future when I began the

sessions, mostly due to the fact that my sister had very recently died of cancer and I felt

extremely upset and discouraged about my own health chances in the future. [I] feel

much more positive about it now."

Theme: Issue with the Therapy Program. Although the large majority of

participants described a positive experience from participating in the programs, two

participants indicated they did not feel they experienced many benefits from the program.

The main concern reported by these two participants was that they did not feel the

program adequately addressed their concerns or problems, and, thus, they did not receive

the desired benefits. For example, one participant wrote: "I started to doubt as I felt that

it did not address my problems."

172

continue this successfully after the treatment sessions were completed. Participants also

indicated they gained hope that their anxiety and worry could decrease if they continued

to attend therapy and if they practiced the various anxiety management techniques that

were discussed during the sessions. For example, one participant indicated she felt the

program helped improve her worries about her health by "recognizing that I had the

knowledge and confidence to deal with problems." Other participants also indicated that

they felt they gained the knowledge and confidence to more effectively cope with

anxiety: "I feel more confident that I'm doing the right things to cope with anxiety." For

example, when asked if the program helped improve her worries about her health, one

participant wrote that "[It] gave me a better attitude, so I feel more positive about the

future of my health. I felt very negative and depressed about the future when I began the

sessions, mostly due to the fact that my sister had very recently died of cancer and I felt

extremely upset and discouraged about my own health chances in the future. [I] feel

much more positive about it now."

Theme: Issue with the Therapy Program. Although the large majority of

participants described a positive experience from participating in the programs, two

participants indicated they did not feel they experienced many benefits from the program.

The main concern reported by these two participants was that they did not feel the

program adequately addressed their concerns or problems, and, thus, they did not receive

the desired benefits. For example, one participant wrote: "I started to doubt as I felt that

it did not address my problems."

172

3.2 Study 2 — Results

3.2.1 Comparison on Anxiety Measures.

Independent samples t-tests were used to compare the matched control group to

the older adult participants. Hypothesis 1 proposed that the older adult participants

specifically would have significantly higher scores than the control group on the Somatic

Symptoms/Bodily Preoccupation subscale of the WI, the Negative Consequences of

Illness subscale of the SHAI, and the Symptoms Effects subscale of the IAS.

Although the hypothesis was not confirmed, there were a number of significant

differences found between the two groups (see Table 30). The matched control group

had significantly higher scores than the older adult group on the SHAI, t(112) = -4.16,p

— .0001; IAS, t(112) = -2.22,p = .03; SSI, t(112) = --3.22,p = .002; HCQ, t(112) = -2.98,

p = .003; ASI, t(112) = -8.33,p = .0001; STAI-S, t(112) = -3.39,p = .001; and STAI-T,

t(112) = -5.34, p = .0001. The matched control group also had significantly higher scores

than the older adult group on various WI, SHAI, and IAS subscales, including IAS — Fear

of Illness and Pain, t(112) = -2.70,p = .008; IAS — Symptom Effects, t(112) = -3.51,p —

.001. The older adult group had significantly higher scores than the matched control

group on WI — Disease Fear/Phobia, t(112) = -2.24,p = .03.

173

3.2 Study 2 - Results

3.2.1 Comparison on Anxiety Measures.

Independent samples /-tests were used to compare the matched control group to

the older adult participants. Hypothesis 1 proposed that the older adult participants

specifically would have significantly higher scores than the control group on the Somatic

Symptoms/Bodily Preoccupation subscale of the WI, the Negative Consequences of

Illness subscale of the SHAI, and the Symptoms Effects subscale of the IAS.

Although the hypothesis was not confirmed, there were a number of significant

differences found between the two groups (see Table 30). The matched control group

had significantly higher scores than the older adult group on the SHAI, t(l 12) = -4.16, p

= .0001; IAS, t(l 12) = -2.22, p = .03; SSI, t(\ 12) = --3.22,/? = .002; HCQ, t(\ 12) = -2.98,

p = .003; ASI, t(U2) = -8.33,/? = .0001; STAI-S, t(U2) = -3.39,/? = .001; and STAI-T,

t(l 12) = -5.34, p = .0001. The matched control group also had significantly higher scores

than the older adult group on various WI, SHAI, and IAS subscales, including IAS - Fear

of Illness and Pain, t(\ 12) = -2.70, p = .008; IAS - Symptom Effects, /(l 12) = -3.51, p =

.001. The older adult group had significantly higher scores than the matched control

group on WI - Disease Fear/Phobia, t(\ 12) = -2.24,p = .03.

173

Table 31

Scale Scores for Matched Participants

Measure Older Adult Matched

Group Control Group

M (SD) M (SD) t

Whiteley Index

Total Score 9.11 1.22 9.12 1.23 -.06

Somatic Symptoms 1.68 .93 1.75 .46 -.39

Disease Fear/Phobia 2.70 1.01 2.44 .76 2.24*


Total Score 15.99 5.00 19.94 5.13 -4.16***

Negative Consequences 2.30 .31 2.48 .33 -.98


Total 49.46 11.20 54.54 13.16 -2.22*

Fear of Illness and Pain 13.42 5.74 16.89 7.86 -2.70**

Symptom Effects 6.67 2.83 8.54 2.86 -3.51**

Treatment Experience 9.20 2.63 9.25 2.92 -.09

Disease Conviction 4.98 2.98 5.43 2.66 -.86

Somatic Symptom Inventory 31.62 7.05 36.75 9.77 -3.22**

Somatosensory Amplification Scale 28.17 5.59 27.97 6.77 .18

Health Cognitions Questionnaire 29.53 8.57 35.80 13.35 -2.98**

Anxiety Sensitivity Index 27.47 10.80 45.32 12.05 -8.33***

174

Table 31

Scale Scores for Matched Participants

Measure Older Adult

Group

Matched

Control Group

Whiteley Index

Total Score

Somatic Symptoms

Disease Fear/Phobia


Total Score

Negative Consequences


Total

Fear of Illness and Pain

Symptom Effects

Treatment Experience

Disease Conviction

M (SD)

9.11 1.22

1.68 .93

2.70 1.01

15.99 5.00

2.30 .31

49.46 11.20

13.42 5.74

6.67 2.83

9.20 2.63

4.98 2.98

Somatic Symptom Inventory 31.62 7.05

Somatosensory Amplification Scale 28.17 5.59

Health Cognitions Questionnaire 29.53 8.57

Anxiety Sensitivity Index 27.47 10.80

M (SD)

9.12 1.23

1.75 .46

2.44 .76

2.48 .33

16.89 7.86

9.25 2.92

5.43 2.66

36.75 9.77

.06

-.39

2.24'

19.94 5.13 -4.16 * * *

-.98

54.54 13.16 -2.22*

-2.70 * *

8.54 2.86 -3.51**

.09

.86

-3.22**

27.97 6.77 .18

35.80 13.35 -2.98**

45.32 12.05 -8.33***

174


Group Control Group

M (SD) M (SD) t

State Trait Anxiety Inventory — State 40.76 10.61 47.03 9.12 -3.39**

State Trait Anxiety Inventory — Trait 44.45 10.00 54.44 9.99 -5.34***

Note. WI — Somatic Symptoms = Whiteley Index — Somatic Symptoms/Bodily

Preoccupation; *p < .05, **p < .01, ***p < .001

175


Group Control Group

M (SD) M (SD) t

State Trait Anxiety Inventory - State 40.76 10.61 47.03 9T2 -3.39**

State Trait Anxiety Inventory - Trait 44.45 10.00 54.44 9.99 -5.34***

Note. WI - Somatic Symptoms = Whiteley Index - Somatic Symptoms/Bodily

Preoccupation; *p < .05, **/? < .01, ***p < .001

175

4. DISCUSSION

Heightened levels of anxiety among older adults are associated with increased

depression (Jeste, Hays, & Steffens, 2006), increased morbidity (Ostir & Goodwin, 2006),

chronic health conditions (Diala & Muntaner, 2003), and markedly higher health care costs

(Simon, Ormel, VonKoff, & Barlow, 1995). Although aging does not inevitably result in

increases in health anxiety (Boston & Merrick, 2010; Bourgault-Fagnou &

Hadjistavropoulos, 2009), the negative effects of anxiety validate the importance of

having effective methods for reducing health anxiety among the older adult population.

Unfortunately, one of the significant limitations of the health anxiety treatment

literature is the almost exclusive focus on younger adults. Seniors have been consistently

underrepresented in research on health anxiety in spite of how common health concerns

are in the lives of older adults. Thus, most of the literature on health anxiety does not

focus attention on the unique concerns of older adults with health anxiety and specifically

on the outcome of treatment in this population. As a result, questions have been raised

about the appropriateness of generalising psychological interventions for health anxiety

developed and tested with younger adults to seniors (Snyder & Stanley, 2001). There is

empirical support, although very limited, that the CB model of health anxiety may be

applicable to older adults (Boston & Merrick, 2010). There is other evidence with other

psychological disorders that it is important to adapt treatment to meet the needs of older

adults, taking into account the changes that occur through the aging process (Mohlman et

al., 2003; Stanley, Diefenbach, Hopko, 2004). As such, psychological treatments based

176

4. DISCUSSION

Heightened levels of anxiety among older adults are associated with increased

depression (Jeste, Hays, & Steffens, 2006), increased morbidity (Ostir & Goodwin, 2006),

chronic health conditions (Diala & Muntaner, 2003), and markedly higher health care costs

(Simon, Ormel, VonKoff, & Barlow, 1995). Although aging does not inevitably result in

increases in health anxiety (Boston & Merrick, 2010; Bourgault-Fagnou &

Hadjistavropoulos, 2009), the negative effects of anxiety validate the importance of

having effective methods for reducing health anxiety among the older adult population.

Unfortunately, one of the significant limitations of the health anxiety treatment

literature is the almost exclusive focus on younger adults. Seniors have been consistently

underrepresented in research on health anxiety in spite of how common health concerns

are in the lives of older adults. Thus, most of the literature on health anxiety does not

focus attention on the unique concerns of older adults with health anxiety and specifically

on the outcome of treatment in this population. As a result, questions have been raised

about the appropriateness of generalising psychological interventions for health anxiety

developed and tested with younger adults to seniors (Snyder & Stanley, 2001). There is

empirical support, although very limited, that the CB model of health anxiety may be

applicable to older adults (Boston & Merrick, 2010). There is other evidence with other

psychological disorders that it is important to adapt treatment to meet the needs of older

adults, taking into account the changes that occur through the aging process (Mohlman et

al., 2003; Stanley, Diefenbach, Hopko, 2004). As such, psychological treatments based

176

on CB principles and with specific adaptations for older adults may be useful in treating

older adults with health anxiety.

The aim of the present study was to gain a better understanding of health anxiety

among older adults and to assess the efficacy of ECBT for health anxiety for older adults,

in comparison to a SCBT treatment and a WLC condition. Fifty-seven older adults with

health anxiety were randomly assigned to one of the three treatment conditions and were

assessed at pre- and post-treatment. Participants in both the experimental groups were

also assessed at three months following the end of treatment. The analyses addressed

several other relevant issues, including an examination of the therapeutic alliance,

motivation for psychotherapy, and clinical significance of the treatments for older adults

in the two treatment groups. Furthermore, we aimed to gain a greater understanding of

the nature of health anxiety and the experience of therapy among older adults through

qualitative analysis of open-ended questions. Finally, with this dataset we were able to

determine if older adults scored differently on health anxiety measures compared to a

younger adult sample by examining the differences between the older adult group and a

younger adult group control group. Findings from the study and how they inform the CB

model and current treatment protocols are discussed below.

4.1 Assessment of Hypotheses

According to Hypothesis 1, participants receiving SCBT and ECBT, but not those

in WLC group, would evidence improvements in health anxiety, frequency of


bodily symptoms as distressing, state and trait anxiety, depression, pain, and health-

177

on CB principles and with specific adaptations for older adults may be useful in treating

older adults with health anxiety.

The aim of the present study was to gain a better understanding of health anxiety

among older adults and to assess the efficacy of ECBT for health anxiety for older adults,

in comparison to a SCBT treatment and a WLC condition. Fifty-seven older adults with

health anxiety were randomly assigned to one of the three treatment conditions and were

assessed at pre- and post-treatment. Participants in both the experimental groups were

also assessed at three months following the end of treatment. The analyses addressed

several other relevant issues, including an examination of the therapeutic alliance,

motivation for psychotherapy, and clinical significance of the treatments for older adults

in the two treatment groups. Furthermore, we aimed to gain a greater understanding of

the nature of health anxiety and the experience of therapy among older adults through

qualitative analysis of open-ended questions. Finally, with this dataset we were able to

determine if older adults scored differently on health anxiety measures compared to a

younger adult sample by examining the differences between the older adult group and a

younger adult group control group. Findings from the study and how they inform the CB

model and current treatment protocols are discussed below.

4.1 Assessment of Hypotheses

According to Hypothesis 1, participants receiving SCBT and ECBT, but not those

in WLC group, would evidence improvements in health anxiety, frequency of


bodily symptoms as distressing, state and trait anxiety, depression, pain, and health-

177

related quality of life from pre-treatment to post-treatment. The results of the analyses

examining change from pre-treatment to post-treatment were mixed. Consistent with the

hypothesis, individuals receiving SCBT and ECBT showed significantly lower levels of

health anxiety (as measured by the WI), with reductions on the subscale measuring

disease fear/phobia, when compared to the WLC group. No other significant differences

were found at post-treatment on the primary outcome measures.

When viewing the results on the secondary outcome measures, individuals

receiving the SCBT showed significantly improved scores on the physical component of

health-related quality of life (SF-12-PCS; a high score equals higher physical health

related quality of life) when compared to the WLC group from pre-treatment to post-

treatment. No other significant differences were found on the secondary outcome

measures.

In order to evaluate the long-term effectiveness of the CBT programs,

questionnaires were completed by the experimental participants (but for ethical reasons

not the WLC participants) three months following the completion of the therapy program.

Hypothesis 2 indicated that participants treated with ECBT would demonstrate the

greatest overall improvement at post-treatment and follow-up on each of the measures

indicated in the first hypothesis. For participants treated with both SCBT and ECBT, all

expected improvements would be maintained three months following the conclusion of

treatment. Again, the findings were mixed. Improvements in scores on the WI and

Disease Fear/Phobia for participants in both treatment groups were maintained. There

were no significant declines on the measures, with the exception of one measure, in the

178

related quality of life from pre-treatment to post-treatment. The results of the analyses

examining change from pre-treatment to post-treatment were mixed. Consistent with the

hypothesis, individuals receiving SCBT and ECBT showed significantly lower levels of

health anxiety (as measured by the WI), with reductions on the subscale measuring

disease fear/phobia, when compared to the WLC group. No other significant differences

were found at post-treatment on the primary outcome measures.

When viewing the results on the secondary outcome measures, individuals

receiving the SCBT showed significantly improved scores on the physical component of

health-related quality of life (SF-12-PCS; a high score equals higher physical health

related quality of life) when compared to the WLC group from pre-treatment to post-

treatment. No other significant differences were found on the secondary outcome

measures.

In order to evaluate the long-term effectiveness of the CBT programs,

questionnaires were completed by the experimental participants (but for ethical reasons

not the WLC participants) three months following the completion of the therapy program.

Hypothesis 2 indicated that participants treated with ECBT would demonstrate the

greatest overall improvement at post-treatment and follow-up on each of the measures

indicated in the first hypothesis. For participants treated with both SCBT and ECBT, all

expected improvements would be maintained three months following the conclusion of

treatment. Again, the findings were mixed. Improvements in scores on the WI and

Disease Fear/Phobia for participants in both treatment groups were maintained. There

were no significant declines on the measures, with the exception of one measure, in the

178

three months following the end of treatment. Individuals in the SCBT group evidenced

an increase in state anxiety (STAI-S) and the ECBT group evidenced a slight decline in

state anxiety. However, there were no other significant differences found between SCBT

and ECBT, indicating that, overall, ECBT did not demonstrate that greatest overall

improvement when compared to SCBT.

While the results of the effectiveness of the two active treatment programs were

not entirely consistent with predictions, results provided a number of important insights

about the treatment of health anxiety among older adults. First, these findings provide

some support for both SCBT and ECBT as effective treatments for addressing certain

cognitive and behavioural aspects of health anxiety as well as the physical component of

health-related quality of life. Both programs appeared effective in reducing fear of

having or developing a serious illness. These findings are consistent with other studies

examining the efficacy of CBT for health anxiety (e.g., Barsky & Ahern, 2004;

Seivewright et al., 2008; Sorensen et al., in press; Visser & Bouman, 2001; Warwick et

al., 1996), which have consistently shown that CBT is effective in reducing health

anxiety.

Overall, it appears that the components of our CBT program successfully targeted

specific variables for change. For instance, there is evidence to suggest that the CBT

programs challenged some of the maladaptive thoughts and beliefs seniors were having

around the fear of having a disease. This is important because these beliefs (e.g., that one

should be fearful of disease) are hypothesized to have a negative impact on mood and

anxiety as well as on behaviours that maintain problematic beliefs (e.g., reassurance

179

three months following the end of treatment. Individuals in the SCBT group evidenced

an increase in state anxiety (STAI-S) and the ECBT group evidenced a slight decline in

state anxiety. However, there were no other significant differences found between SCBT

and ECBT, indicating that, overall, ECBT did not demonstrate that greatest overall

improvement when compared to SCBT.

While the results of the effectiveness of the two active treatment programs were

not entirely consistent with predictions, results provided a number of important insights

about the treatment of health anxiety among older adults. First, these findings provide

some support for both SCBT and ECBT as effective treatments for addressing certain

cognitive and behavioural aspects of health anxiety as well as the physical component of

health-related quality of life. Both programs appeared effective in reducing fear of

having or developing a serious illness. These findings are consistent with other studies

examining the efficacy of CBT for health anxiety (e.g., Barsky & Ahern, 2004;

Seivewright et al., 2008; Sorensen et al., in press; Visser & Bouman, 2001; Warwick et

al., 1996), which have consistently shown that CBT is effective in reducing health

anxiety.

Overall, it appears that the components of our CBT program successfully targeted

specific variables for change. For instance, there is evidence to suggest that the CBT

programs challenged some of the maladaptive thoughts and beliefs seniors were having

around the fear of having a disease. This is important because these beliefs (e.g., that one

should be fearful of disease) are hypothesized to have a negative impact on mood and

anxiety as well as on behaviours that maintain problematic beliefs (e.g., reassurance

179

seeking, focusing attention on bodily symptoms, bodily checking, avoidance) (Salkovskis

& Warwick, 2001).

Second, fears and beliefs related to illness decreased in comparison to somatic

symptoms. This finding, when examined, appears to make sense. Both treatment

protocols (SCBT and ECBT), which were based on Barsky and Ahern's (2004) CBT for

hypochondriasis, were intended to improve coping with symptoms rather than

eliminating them outright. In designing the treatment, Barsky and Ahern (2004)

indicated that individuals generally have better treatment outcomes when they learn to

cope with distressing bodily sensations rather than attempting to eliminate their somatic

sensations. Barsky and Ahern (2004) also explained that, conceptually, hypochondriacal

somatic symptoms cannot simply be stripped away with symptomatic treatment because

they exist for underlying psychological and interpersonal reasons. As such, it appears

that realistic goals in treating health anxiety include a reduction in fears and beliefs that

are distressing and an improvement in coping, rather than the elimination of somatic

symptoms.

However, improvement on the primary and secondary outcome measures in both

studies was relatively low when compared to what is typically seen in younger health

anxious samples. For example, Barsky and Ahern (2004) found that participants treated

with CBT significantly improved on measures of health anxiety (WI and SHAI),

hypochondriacal thought frequency, and somatosensory amplification. Seivewright et al.

(2008) and Sorenson et al. (2010) found that participants showed significantly greater

improvement on health anxiety as measured by the SHAI. Further, in clinical trials of

180

seeking, focusing attention on bodily symptoms, bodily checking, avoidance) (Salkovskis

& Warwick, 2001).

Second, fears and beliefs related to illness decreased in comparison to somatic

symptoms. This finding, when examined, appears to make sense. Both treatment

protocols (SCBT and ECBT), which were based on Barsky and Ahern's (2004) CBT for

hypochondriasis, were intended to improve coping with symptoms rather than

eliminating them outright. In designing the treatment, Barsky and Ahern (2004)

indicated that individuals generally have better treatment outcomes when they learn to

cope with distressing bodily sensations rather than attempting to eliminate their somatic

sensations. Barsky and Ahern (2004) also explained that, conceptually, hypochondriacal

somatic symptoms cannot simply be stripped away with symptomatic treatment because

they exist for underlying psychological and interpersonal reasons. As such, it appears

that realistic goals in treating health anxiety include a reduction in fears and beliefs that

are distressing and an improvement in coping, rather than the elimination of somatic

symptoms.

However, improvement on the primary and secondary outcome measures in both

studies was relatively low when compared to what is typically seen in younger health

anxious samples. For example, Barsky and Ahern (2004) found that participants treated

with CBT significantly improved on measures of health anxiety (WI and SHAI),

hypochondriacal thought frequency, and somatosensory amplification. Seivewright et al.

(2008) and Sorenson et al. (2010) found that participants showed significantly greater

improvement on health anxiety as measured by the SHAI. Further, in clinical trials of

180

CBT for health anxiety, reductions in associated symptoms (e.g., generalised anxiety,

depression) have also been found. For example, Seivewright et al. (2008) and Sorenson

et al. (2010) found that generalized anxiety and depression significantly improved in

individuals treated with CBT when compared with a control group. Given the differences

in findings, there are some possible explanations. First, our results may suggest that

health anxiety in late-life is more entrenched than health anxiety occurring in young

adulthood. Thus, older adults may require more than six sessions of treatment for

significant improvements to occur. In addition, it may be possible that CBT is not as

effective in older individuals with elevated health anxiety as it is in younger adults. Also,

because the improvements in levels of health anxiety were somewhat limited, there may

not have been the opportunity for accompanying reductions in anxiety sensitivity,

generalised anxiety, mood, and pain.

Another potential explanation for the lack of findings in our study is the small

sample size and statistical power needed to detect true differences between groups

(Tabachnick & Fidell, 2001). As described above, the outcome measures from pre- to

post-treatment and post-treatment to follow-up evidenced some, but only limited,

statistically significant change in those receiving the two treatments versus WLC. The

change demonstrated by the SCBT and ECBT participants was generally not significantly

greater than the change demonstrated by participants in WLC group, with the exception

of health anxiety (WI) and the physical component of health-related quality of life (SF-

12-PCS). However, the results of the paired sample t-tests and the examination of

clinically significant change suggest that improvements did occur in both the SCBT and

181

CBT for health anxiety, reductions in associated symptoms (e.g., generalised anxiety,

depression) have also been found. For example, Seivewright et al. (2008) and Sorenson

et al. (2010) found that generalized anxiety and depression significantly improved in

individuals treated with CBT when compared with a control group. Given the differences

in findings, there are some possible explanations. First, our results may suggest that

health anxiety in late-life is more entrenched than health anxiety occurring in young

adulthood. Thus, older adults may require more than six sessions of treatment for

significant improvements to occur. In addition, it may be possible that CBT is not as

effective in older individuals with elevated health anxiety as it is in younger adults. Also,

because the improvements in levels of health anxiety were somewhat limited, there may

not have been the opportunity for accompanying reductions in anxiety sensitivity,

generalised anxiety, mood, and pain.

Another potential explanation for the lack of findings in our study is the small

sample size and statistical power needed to detect true differences between groups

(Tabachnick & Fidell, 2001). As described above, the outcome measures from pre- to

post-treatment and post-treatment to follow-up evidenced some, but only limited,

statistically significant change in those receiving the two treatments versus WLC. The

change demonstrated by the SCBT and ECBT participants was generally not significantly

greater than the change demonstrated by participants in WLC group, with the exception

of health anxiety (WI) and the physical component of health-related quality of life (SF-

12-PCS). However, the results of the paired sample t-tests and the examination of

clinically significant change suggest that improvements did occur in both the SCBT and

181

ECBT groups after treatment; but given the small sample size and limited statistical

power, these improvements were not evidenced in the repeated measures analyses.

More specifically, the results of the paired samples t-tests indicated that

participants in the SCBT treatment group demonstrated significant improvements from

pre- to post-treatment on measures of health anxiety (WI, HAI, IAS) and their subscales

of Somatic Symptoms/Bodily Preoccupation, Disease Fear/Phobia (WI); Negative

Consequences (SHAI); Symptom Effects (IAS); state and trait anxiety; depression; and

health-related quality of life — mental and physical; and from post-treatment to follow-up

on state anxiety and the physical component of health-related quality of life (SF-12-PCS).

Participants in the ECBT treatment group demonstrated significant improvements from

pre- to post-treatment on measures of health anxiety (WI, SHAD and their subscales of

Somatic Symptoms/Bodily Preoccupation, Disease Fear/Phobia (WI); hypochondriacal

somatic symptoms (S SI); anxiety sensitivity; and depression; and from post-treatment to

follow-up on IAS health anxiety, and the subscales of Symptom Effects and Treatment

Experience; and Disease Fear/Phobia (WI). To the contrary, there was only one

improvement evidenced on any of the DVs for the WLC group from pre-treatment to

post-treatment, which was the physical component of health-related quality of life (SF-

12-PCS).

In addition, the changes that did occur from post-treatment to follow-up in our

study appeared to be maintained in both groups. This is consistent with a number of

studies examining the efficacy of CBT for health anxiety among younger adults (e.g.,

Seivewright et al., 2008; Sorensen et al., in press). Researchers have generally found that

182

ECBT groups after treatment; but given the small sample size and limited statistical

power, these improvements were not evidenced in the repeated measures analyses.

More specifically, the results of the paired samples Mests indicated that

participants in the SCBT treatment group demonstrated significant improvements from

pre- to post-treatment on measures of health anxiety (WI, HAI, IAS) and their subscales

of Somatic Symptoms/Bodily Preoccupation, Disease Fear/Phobia (WI); Negative

Consequences (SHAI); Symptom Effects (IAS); state and trait anxiety; depression; and

health-related quality of life - mental and physical; and from post-treatment to follow-up

on state anxiety and the physical component of health-related quality of life (SF-12-PCS).

Participants in the ECBT treatment group demonstrated significant improvements from

pre- to post-treatment on measures of health anxiety (WI, SHAI) and their subscales of

Somatic Symptoms/Bodily Preoccupation, Disease Fear/Phobia (WI); hypochondriacal

somatic symptoms (SSI); anxiety sensitivity; and depression; and from post-treatment to

follow-up on IAS health anxiety, and the subscales of Symptom Effects and Treatment

Experience; and Disease Fear/Phobia (WI). To the contrary, there was only one

improvement evidenced on any of the DVs for the WLC group from pre-treatment to

post-treatment, which was the physical component of health-related quality of life (SF-

12-PCS).

In addition, the changes that did occur from post-treatment to follow-up in our

study appeared to be maintained in both groups. This is consistent with a number of

studies examining the efficacy of CBT for health anxiety among younger adults (e.g.,

Seivewright et al., 2008; Sorensen et al., in press). Researchers have generally found that

182

treatment gains are often maintained with CBT. For example, Barsky and Ahern (2004)

found that gains on health anxiety, frequency of hypochondriacal thoughts, and

somatosensory amplification were maintained and 6- and 12-months follow-ups.

Further evidence for the effectiveness of our CBT programs for treating health

anxiety in older adults comes from an examination of clinically significant change

defined by Jacobson and Truax (1992). These authors indicated that clinically significant

change could be determined when post-treatment scores fall outside two standard

deviations of the mean of the population being examined. Of the 21 participants who

were assigned to and completed the SCBT treatment, of the 18 participants who were

assigned to and completed the ECBT treatment, and of the 18 participant who were

assigned to the WLC group, 14 of the SCBT group, 10 of the ECBT group, and 2 of the

WLC group finished with WI scores less than 8 — the score necessary for initial inclusion

in the trial. Thus, not only did 66.7% of the SCBT participants and 55.6% of ECBT

participants no longer meet criteria for elevated health anxiety as measured by the WI,

these improvements were significantly greater than those demonstrated by individuals in

the WLC group (only 11% made improvements), suggesting that both SCBT and ECBT

are effective treatments for reducing health anxiety as measured by the WI. These

findings appear consistent with those reported by Greeven et al. (2007), who found that

45% of the CBT participants had a decrease of more than one standard deviation on the

main outcome measure as opposed to a 14% decrease in the placebo group.

Qualitative analysis of post-treatment responses also provided evidence for the

effectiveness of our CBT programs for treating health anxiety in older adults. When

183

treatment gains are often maintained with CBT. For example, Barsky and Ahern (2004)

found that gains on health anxiety, frequency of hypochondriacal thoughts, and

somatosensory amplification were maintained and 6- and 12-months follow-ups.

Further evidence for the effectiveness of our CBT programs for treating health

anxiety in older adults comes from an examination of clinically significant change

defined by Jacobson and Truax (1992). These authors indicated that clinically significant

change could be determined when post-treatment scores fall outside two standard

deviations of the mean of the population being examined. Of the 21 participants who

were assigned to and completed the SCBT treatment, of the 18 participants who were

assigned to and completed the ECBT treatment, and of the 18 participant who were

assigned to the WLC group, 14 of the SCBT group, 10 of the ECBT group, and 2 of the

WLC group finished with WI scores less than 8 - the score necessary for initial inclusion

in the trial. Thus, not only did 66.7% of the SCBT participants and 55.6% of ECBT

participants no longer meet criteria for elevated health anxiety as measured by the WI,

these improvements were significantly greater than those demonstrated by individuals in

the WLC group (only 11 % made improvements), suggesting that both SCBT and ECBT

are effective treatments for reducing health anxiety as measured by the WI. These

findings appear consistent with those reported by Greeven et al. (2007), who found that

45%) of the CBT participants had a decrease of more than one standard deviation on the

main outcome measure as opposed to a 14% decrease in the placebo group.

Qualitative analysis of post-treatment responses also provided evidence for the

effectiveness of our CBT programs for treating health anxiety in older adults. When

183

asked whether they felt the program helped improve their worries about health, all but

two participants reported they experienced a number of benefits from engaging in the

therapy experience. Participants indicated they gained knowledge and skills to help

improve their ability to cope with their health anxiety and related issues. Others

indicated that their experiences with health anxiety were normalized during therapy and

they felt less different from other people. Participants reported an improvement in their

ability to engage in self-care by taking time for themselves without guilt. Others reported

an increase in insight and awareness about themselves and their issues with health

anxiety, and an increase in confidence that they could effectively manage their anxiety

and worry. Finally, participants indicated that they gained confidence and autonomy that

they could effectively manage their anxiety and worry even after treatment was

completed.

Additionally, participants were surveyed about what they believed to be helpful

during the therapy experience. They identified a number of components which they

found to be most helpful in improving their coping. Participants indicated that the act of

talking to someone about their issues was beneficial. Also reported was that the inclusion

of specific self-management skills such as relaxation techniques, cognitive restructuring,

and distraction techniques was helpful to participants during treatment. In addition,

education and information on health anxiety and the assignment of homework for weekly

practice were indicated as important aspects of therapy. Only two participants indicated

they did not feel they experienced many benefits from the program. The main concern

reported was that the program did not adequately address their concerns or problems.

184

asked whether they felt the program helped improve their worries about health, all but

two participants reported they experienced a number of benefits from engaging in the

therapy experience. Participants indicated they gained knowledge and skills to help

improve their ability to cope with their health anxiety and related issues. Others

indicated that their experiences with health anxiety were normalized during therapy and

they felt less different from other people. Participants reported an improvement in their

ability to engage in self-care by taking time for themselves without guilt. Others reported

an increase in insight and awareness about themselves and their issues with health

anxiety, and an increase in confidence that they could effectively manage their anxiety

and worry. Finally, participants indicated that they gained confidence and autonomy that

they could effectively manage their anxiety and worry even after treatment was

completed.

Additionally, participants were surveyed about what they believed to be helpful

during the therapy experience. They identified a number of components which they

found to be most helpful in improving their coping. Participants indicated that the act of

talking to someone about their issues was beneficial. Also reported was that the inclusion

of specific self-management skills such as relaxation techniques, cognitive restructuring,

and distraction techniques was helpful to participants during treatment. In addition,

education and information on health anxiety and the assignment of homework for weekly

practice were indicated as important aspects of therapy. Only two participants indicated

they did not feel they experienced many benefits from the program. The main concern

reported was that the program did not adequately address their concerns or problems.

184

These qualitative findings are consistent with the CB treatment literature, which

indicates that CBT that includes such components as education and information, the

teaching and provision of specific self-management skills (e.g., behavioural, emotional,

and cognitive), and assignment of homework are effective in the treatment of various

disorders including hypochondriasis (e.g., Barsky & Ahern, 2004; Seivewright et al.,

2008). These findings are also consistent with other qualitative investigations of

participants' experiences of psychotherapy. For example, Timulak (2007) applied meta-

analytic procedures to qualitative studies indentifying key client experiences repeatedly

described as helpful in psychotherapy. Timulak's (2007) findings indicated that through

psychotherapy, participants gained awareness/insight/self-understanding; new strategies

to attain goals; empowerment; relief; emotional exploration/experiencing; the feeling of

being understood; an opportunity for active participation; reassurance/support/safety; and

personal contact with a fellow human being.

Finally, the results from the supplementary analyses examining change in the

WLC group where participants were used as their own controls by observing changes in

baseline, post-baseline of six weeks without treatment, and post-treatment with ECBT

scores on all measures also provided evidence to the effectiveness of CBT for health

anxiety among older adults. These results indicated that participants demonstrated

significant improvements after receiving ECBT on measures of health anxiety (WI and

SHAI) that were not observed while they were waiting.

The results from the paired samples t-tests, examination of clinical change,

examination of the maintenance of gains, qualitative analysis of the post-treatment

185

These qualitative findings are consistent with the CB treatment literature, which

indicates that CBT that includes such components as education and information, the

teaching and provision of specific self-management skills (e.g., behavioural, emotional,

and cognitive), and assignment of homework are effective in the treatment of various

disorders including hypochondriasis (e.g., Barsky & Ahern, 2004; Seivewright et al.,

2008). These findings are also consistent with other qualitative investigations of

participants' experiences of psychotherapy. For example, Timulak (2007) applied meta-

analytic procedures to qualitative studies indentifying key client experiences repeatedly

described as helpful in psychotherapy. Timulak's (2007) findings indicated that through

psychotherapy, participants gained awareness/insight/self-understanding; new strategies

to attain goals; empowerment; relief; emotional exploration/experiencing; the feeling of

being understood; an opportunity for active participation; reassurance/support/safety; and

personal contact with a fellow human being.

Finally, the results from the supplementary analyses examining change in the

WLC group where participants were used as their own controls by observing changes in

baseline, post-baseline of six weeks without treatment, and post-treatment with ECBT

scores on all measures also provided evidence to the effectiveness of CBT for health

anxiety among older adults. These results indicated that participants demonstrated

significant improvements after receiving ECBT on measures of health anxiety (WI and

SHAI) that were not observed while they were waiting.

The results from the paired samples t-tests, examination of clinical change,

examination of the maintenance of gains, qualitative analysis of the post-treatment

185

responses, and findings from our supplementary analyses are consistent with previous

studies examining treatment of CBT. As such, they are important because they suggest

that SCBT and ECBT are more effective than was suggested by our other analyses.

However, additional evidence will be needed before any of these possible explanations

can be argued strongly. Thus, given these findings, further research with larger samples

of older adults appears to be warranted.

With respect to the lack of evidence that ECBT was superior to SCBT, examination

of the findings related to therapeutic alliance and motivation for psychotherapy could

potentially help to explain this finding. Hypotheses 4 and 5 stated, respectively, that


and motivation for psychotherapy at three and six weeks than those receiving SCBT.

These hypotheses, for the most part, were not confirmed. When comparing the two

groups on the therapeutic alliance and motivation for psychotherapy, there was only one

significant difference found between the SCBT and ECBT groups, which was on the

WAI — Goals subscale, which measures agreement between client and therapist about

treatment goals or areas targeted for change. The SCBT group had significantly higher

scores on the WAI — Goals subscale at follow-up when compared to the ECBT group,

suggesting that participants in the SCBT had an increase in agreement with the therapist

about treatment goals.

In addition, in the supplementary analyses examining the relationship between

degree of change in health anxiety from pre-treatment to post-treatment and the

therapeutic relationship and motivation for psychotherapy at post-treatment, there were

186

responses, and findings from our supplementary analyses are consistent with previous

studies examining treatment of CBT. As such, they are important because they suggest

that SCBT and ECBT are more effective than was suggested by our other analyses.

However, additional evidence will be needed before any of these possible explanations

can be argued strongly. Thus, given these findings, further research with larger samples

of older adults appears to be warranted.

With respect to the lack of evidence that ECBT was superior to SCBT, examination

of the findings related to therapeutic alliance and motivation for psychotherapy could

potentially help to explain this finding. Hypotheses 4 and 5 stated, respectively, that


and motivation for psychotherapy at three and six weeks than those receiving SCBT.

These hypotheses, for the most part, were not confirmed. When comparing the two

groups on the therapeutic alliance and motivation for psychotherapy, there was only one

significant difference found between the SCBT and ECBT groups, which was on the

WAI - Goals subscale, which measures agreement between client and therapist about

treatment goals or areas targeted for change. The SCBT group had significantly higher

scores on the WAI - Goals subscale at follow-up when compared to the ECBT group,

suggesting that participants in the SCBT had an increase in agreement with the therapist

about treatment goals.

In addition, in the supplementary analyses examining the relationship between

degree of change in health anxiety from pre-treatment to post-treatment and the

therapeutic relationship and motivation for psychotherapy at post-treatment, there were

186

no significant relationships found between outcome and the therapeutic alliance. When

examining outcome and motivation for psychotherapy, there were very few significant

relationships found. However, in participants treated with SCBT, lower levels of Doubt

(i.e., doubt about the investment in treatment, the treatment itself, and the possibility of

gaining from it) at Session 6 were found to be related to greater improvements in health

anxiety as measured by the WI change score from pre-treatment to post-treatment. In the

ECBT group, lower levels of Distress (i.e., pressure by others and level of distress) at

Session 6 were related to greater improvements in health anxiety as measured by the WI

change score from pre-treatment to post-treatment.

Although building the alliance and motivating patients for treatment was a focus

in the ECBT program, there is limited evidence to suggest that ECBT was superior to

SCBT. This was somewhat surprising initially. The ECBT program was specifically

designed for older adults and extra components were added which included weekly

reading assignments meant to reinforce session material, graphing exercises in which

participants chart numerical mood ratings averaged over each week, mid-week

homework reminder/troubleshooting calls from the therapist for the first four

assignments, a perspective-taking strategy (described above) to facilitate evidence

generation in cognitive restructuring exercises, and short videos with an older adult

giving personal testimonials about the program. Although we attempted to incorporate

components into our programs that would help to engage participants in therapy, given

the results from the supplementary analysis, it appears as though these enhancements

187

no significant relationships found between outcome and the therapeutic alliance. When

examining outcome and motivation for psychotherapy, there were very few significant

relationships found. However, in participants treated with SCBT, lower levels of Doubt

(i.e., doubt about the investment in treatment, the treatment itself, and the possibility of

gaining from it) at Session 6 were found to be related to greater improvements in health

anxiety as measured by the WI change score from pre-treatment to post-treatment. In the

ECBT group, lower levels of Distress (i.e., pressure by others and level of distress) at

Session 6 were related to greater improvements in health anxiety as measured by the WI

change score from pre-treatment to post-treatment.

Although building the alliance and motivating patients for treatment was a focus

in the ECBT program, there is limited evidence to suggest that ECBT was superior to

SCBT. This was somewhat surprising initially. The ECBT program was specifically

designed for older adults and extra components were added which included weekly

reading assignments meant to reinforce session material, graphing exercises in which

participants chart numerical mood ratings averaged over each week, mid-week

homework reminder/troubleshooting calls from the therapist for the first four

assignments, a perspective-taking strategy (described above) to facilitate evidence

generation in cognitive restructuring exercises, and short videos with an older adult

giving personal testimonials about the program. Although we attempted to incorporate

components into our programs that would help to engage participants in therapy, given

the results from the supplementary analysis, it appears as though these enhancements

187

may not have been necessary for improving the therapeutic alliance and motivation for

psychotherapy.

Although the findings indicate that ECBT was not superior to SCBT with respect

to enhancing the therapeutic alliance and motivation for psychotherapy, the results do

suggest that lower levels of Distress in the SCBT group and lower levels of Doubt in the

ECBT group were related to improved outcomes. These findings are consistent with

previous research which indicates that motivation is related to outcome in psychotherapy

(Keijsers et al., 1999). The findings also suggest that addressing Doubt and Distress

during therapy sessions could be critical for improving outcomes.

In addition, when examining the scores obtained by participants on the subscales

of the WAI and NML-2, overall, they were found to be higher than average (Horvath &

Greenberg, 1989; Nijmegen et al., 2004). This suggests there may not have been

sufficient room for improvement in scores. This may be due to the fact that our sample

of participants saw the advertisements for the study and then volunteered to take part. As

such, those who completed the therapy already were motivated and eager to help. As a

result, the extra components that were in the ECBT program may not have been

necessary for this sample of participants since they were already motivated and interested

in talking about their problems. Perhaps in different samples with lower motivation and

ability to connect, the ECBT program would be beneficial.

Further evidence that the therapeutic relationship was high was found when

examining participants' responses at post-treatment to open-ended questions. With

respect to the therapeutic relationship, all participants indicated that they felt the

188

may not have been necessary for improving the therapeutic alliance and motivation for

psychotherapy.

Although the findings indicate that ECBT was not superior to SCBT with respect

to enhancing the therapeutic alliance and motivation for psychotherapy, the results do

suggest that lower levels of Distress in the SCBT group and lower levels of Doubt in the

ECBT group were related to improved outcomes. These findings are consistent with

previous research which indicates that motivation is related to outcome in psychotherapy

(Keijsers et al., 1999). The findings also suggest that addressing Doubt and Distress

during therapy sessions could be critical for improving outcomes.

In addition, when examining the scores obtained by participants on the subscales

of the WAI and NML-2, overall, they were found to be higher than average (Horvath &

Greenberg, 1989; Nijmegen et al., 2004). This suggests there may not have been

sufficient room for improvement in scores. This may be due to the fact that our sample

of participants saw the advertisements for the study and then volunteered to take part. As

such, those who completed the therapy already were motivated and eager to help. As a

result, the extra components that were in the ECBT program may not have been

necessary for this sample of participants since they were already motivated and interested

in talking about their problems. Perhaps in different samples with lower motivation and

ability to connect, the ECBT program would be beneficial.

Further evidence that the therapeutic relationship was high was found when

examining participants' responses at post-treatment to open-ended questions. With

respect to the therapeutic relationship, all participants indicated that they felt the

188

therapeutic relationship had been transformative and described positive experiences with

their therapist. They also described the therapist qualities and actions that helped to

establish the therapeutic relationship and foster motivation for therapy. Therapist

qualities reported included being empathic, professional, relaxed, optimistic, friendly,

non-judgemental, trustworthy, genuinely interested in the patient, invested in therapy

outcome, honest, and sincere. Essential therapist actions included being present or face-

to-face, putting the patient at ease, encouraging and reinforcing, communicating belief in

the therapy program, and instilling hope.

Ackerman and Hilsenroth (2003) conducted a review of the literature on therapist

qualities and the therapeutic alliance and the findings revealed that specific therapist's

personal attributes were significantly related to the development and maintenance of a

positive relationship. They also suggest that a possible explanation for these findings is

that the therapist's personal qualities such as dependability, compassion, responsiveness,

and experience help patients gain the confidence and trust that their therapist has the

ability to both understand and help them cope with the issues that brought them to

therapy. Further, a caring and compassionate connection between the patient and

therapist helps create a warm, accepting, and supportive therapeutic climate that may

increase the opportunity for therapeutic patient change. If a patient believes the treatment

relationship is a collaborative effort between her/himself and the therapist, she or he may

be more likely to invest more in the treatment process and in turn experience greater

therapeutic gains. The responses provided by participants in our study appear consistent

with the findings by Ackerman and Hilsenroth (2003).

189

therapeutic relationship had been transformative and described positive experiences with

their therapist. They also described the therapist qualities and actions that helped to

establish the therapeutic relationship and foster motivation for therapy. Therapist

qualities reported included being empathic, professional, relaxed, optimistic, friendly,

non-judgemental, trustworthy, genuinely interested in the patient, invested in therapy

outcome, honest, and sincere. Essential therapist actions included being present or face-

to-face, putting the patient at ease, encouraging and reinforcing, communicating belief in

the therapy program, and instilling hope.

Ackerman and Hilsenroth (2003) conducted a review of the literature on therapist

qualities and the therapeutic alliance and the findings revealed that specific therapist's

personal attributes were significantly related to the development and maintenance of a

positive relationship. They also suggest that a possible explanation for these findings is

that the therapist's personal qualities such as dependability, compassion, responsiveness,

and experience help patients gain the confidence and trust that their therapist has the

ability to both understand and help them cope with the issues that brought them to

therapy. Further, a caring and compassionate connection between the patient and

therapist helps create a warm, accepting, and supportive therapeutic climate that may

increase the opportunity for therapeutic patient change. If a patient believes the treatment

relationship is a collaborative effort between her/himself and the therapist, she or he may

be more likely to invest more in the treatment process and in turn experience greater

therapeutic gains. The responses provided by participants in our study appear consistent

with the findings by Ackerman and Hilsenroth (2003).

189

4.2 Qualitative Analysis Examining Experience of Health Anxiety Among Seniors

In order to gain a greater understanding of the nature of health anxiety and the

experience of therapy among older adults, participant responses to open-ended questions

at pre-treatment were analysed qualitatively. Participants were asked about their

experiences regarding health and anxiety, and they reported a number of common

experiences that were analysed to form a model of the development of health anxiety in

older adults. When questioned about why they believed they experienced difficulties

with anxiety, some participants reported that they believed they had always been anxious

or that anxiety was genetic. Others reported they believed their anxiety to be a learned

response, typically from their parents and from other illness experiences. These results

are consistent with the literature on health anxiety which suggests that genetic and

environmental factors (e.g., learning) both play a role in the development of health

anxiety, although environmental factors appear to play a larger role (Taylor, Thordarson,

Jang, & Asmundson, 2006).

Participants also reported various past and current experiences with illness in

themselves and others as well as the experience of death. Participants' reports of past

experience with illness and death are consistent with the literature outlining the CB

model of health anxiety (Salkovskis & Warwick's, 1986). The CB model indicates that

past experience with illness, (e.g., early health- and illness-related experience, later

events such as unexpected or unpleasant illness in the person's social group, and

information in the media) and death lead to the formation of inflexible or negative

assumptions about symptoms, disease, medical care, and so forth. These negative

190

4.2 Qualitative Analysis Examining Experience of Health Anxiety Among Seniors

In order to gain a greater understanding of the nature of health anxiety and the

experience of therapy among older adults, participant responses to open-ended questions

at pre-treatment were analysed qualitatively. Participants were asked about their

experiences regarding health and anxiety, and they reported a number of common

experiences that were analysed to form a model of the development of health anxiety in

older adults. When questioned about why they believed they experienced difficulties

with anxiety, some participants reported that they believed they had always been anxious

or that anxiety was genetic. Others reported they believed their anxiety to be a learned

response, typically from their parents and from other illness experiences. These results

are consistent with the literature on health anxiety which suggests that genetic and

environmental factors (e.g., learning) both play a role in the development of health

anxiety, although environmental factors appear to play a larger role (Taylor, Thordarson,

Jang, & Asmundson, 2006).

Participants also reported various past and current experiences with illness in

themselves and others as well as the experience of death. Participants' reports of past

experience with illness and death are consistent with the literature outlining the CB

model of health anxiety (Salkovskis & Warwick's, 1986). The CB model indicates that

past experience with illness, (e.g., early health- and illness-related experience, later

events such as unexpected or unpleasant illness in the person's social group, and

information in the media) and death lead to the formation of inflexible or negative

assumptions about symptoms, disease, medical care, and so forth. These negative

190

assumptions then lead to a tendency to initially misinterpret information that is health-

related.

Finally, participants reported a number of dysfunctional core beliefs about the

nature of health and illness (e.g., increased vulnerability or risk for developing various

diseases either due to their poor health habits or to a family history of illness and disease;

fear of death, fear of pain, fear of disability and dependence, and fear of missing out on

life). These findings about dysfunctional beliefs in this older adult sample are consistent

with previous literature examining dysfunctional beliefs in individuals with elevated

health anxiety. Taylor and Asmundson (2004) indicate that health anxiety has a large

cognitive component with anxiety arising from misinterpretations of benign bodily

changes or sensations. In turn, the tendency to misinterpret sensations may be a result of

one's beliefs about sickness and health (Barsky & Klerman, 1983; Salkovskis &

Warwick, 2000). Cognitive studies have shown that individuals with elevated health

anxiety, compared with controls without anxiety, show a greater tendency to overestimate

the likelihood of contracting diseases, and to overestimate the dangerousness of diseases

(Ditto, Jemmott, & Darley, 1988; Easterling & Leventhal, 1989). Individuals with

elevated health anxiety also are more likely to regard themselves as being at greater risk

for developing various diseases, but do not view themselves as being at greater risk for

being the victim of an accident or criminal assault (Barsky et al., 2001; Haenen, de Jong,

Schmidt, Stevens, & Visser, 2000). Further, individuals with elevated health anxiety are

more likely to believe they are weak and unable to tolerate stress (Rief, Hiller, &

Margraf, 1998).

191

assumptions then lead to a tendency to initially misinterpret information that is health-

related.

Finally, participants reported a number of dysfunctional core beliefs about the

nature of health and illness (e.g., increased vulnerability or risk for developing various

diseases either due to their poor health habits or to a family history of illness and disease;

fear of death, fear of pain, fear of disability and dependence, and fear of missing out on

life). These findings about dysfunctional beliefs in this older adult sample are consistent

with previous literature examining dysfunctional beliefs in individuals with elevated

health anxiety. Taylor and Asmundson (2004) indicate that health anxiety has a large

cognitive component with anxiety arising from misinterpretations of benign bodily

changes or sensations. In turn, the tendency to misinterpret sensations may be a result of

one's beliefs about sickness and health (Barsky & Klerman, 1983; Salkovskis &

Warwick, 2000). Cognitive studies have shown that individuals with elevated health

anxiety, compared with controls without anxiety, show a greater tendency to overestimate

the likelihood of contracting diseases, and to overestimate the dangerousness of diseases

(Ditto, Jemmott, & Darley, 1988; Easterling & Leventhal, 1989). Individuals with

elevated health anxiety also are more likely to regard themselves as being at greater risk

for developing various diseases, but do not view themselves as being at greater risk for

being the victim of an accident or criminal assault (Barsky et al., 2001; Haenen, de Jong,

Schmidt, Stevens, & Visser, 2000). Further, individuals with elevated health anxiety are

more likely to believe they are weak and unable to tolerate stress (Rief, Hiller, &

Margraf, 1998).

191

The current qualitative study was intended to guide the application of the CB

theory of health anxiety to older adults. It aimed to provide a more in-depth exploration

of health anxiety experiences in older adults, and was intended to supplement the

experimental study undertaken and outlined above. Given the consistency of our

qualitative findings with previous findings from studies with younger adults and with

information provided by Snyder and Stanley (2001), it is promising that the CB model of

health anxiety can be applied to seniors. However, the following observation should be

taken into consideration in future research and clinical applications of the model to older

adults. In our sample, we had a number of participants experiencing current health-

related issues and significant concern about these problems. Their focus appeared to be

on coping with the current health issues and potential deterioration, rather than on the

possibility of becoming ill in the future. This would fit with Snyder and Stanley's (2001)

hypothesis that seniors with significant levels of health anxiety actually may be unduly

preoccupied with and worried about their existing health problems and symptoms rather

than actually misinterpreting their bodily sensations (Snyder & Stanley, 2001). Future

research with older adults should examine the role of actual illness in health anxiety.

4.3 Comparison of Older and Younger Adults on Health Anxiety

The purpose of Study 2 was to compare a health anxious older adult sample to a

sex and WI score matched health anxious younger adult sample in order to examine

whether the nature of the two groups' concerns on various anxiety measures were

comparable or whether the pattern of responses differed. We hypothesized that

participants in the older group would have significantly higher scores than the control

192

The current qualitative study was intended to guide the application of the CB

theory of health anxiety to older adults. It aimed to provide a more in-depth exploration

of health anxiety experiences in older adults, and was intended to supplement the

experimental study undertaken and outlined above. Given the consistency of our

qualitative findings with previous findings from studies with younger adults and with

information provided by Snyder and Stanley (2001), it is promising that the CB model of

health anxiety can be applied to seniors. However, the following observation should be

taken into consideration in future research and clinical applications of the model to older

adults. In our sample, we had a number of participants experiencing current health-

related issues and significant concern about these problems. Their focus appeared to be

on coping with the current health issues and potential deterioration, rather than on the

possibility of becoming ill in the future. This would fit with Snyder and Stanley's (2001)

hypothesis that seniors with significant levels of health anxiety actually may be unduly

preoccupied with and worried about their existing health problems and symptoms rather

than actually misinterpreting their bodily sensations (Snyder & Stanley, 2001). Future

research with older adults should examine the role of actual illness in health anxiety.

4.3 Comparison of Older and Younger Adults on Health Anxiety

The purpose of Study 2 was to compare a health anxious older adult sample to a

sex and WI score matched health anxious younger adult sample in order to examine

whether the nature of the two groups' concerns on various anxiety measures were

comparable or whether the pattern of responses differed. We hypothesized that

participants in the older group would have significantly higher scores than the control

192

group on the Bodily Preoccupation subscale of the WI, the Body Vigilance subscale of

the SHAI, and the Disruptive Effects of Symptoms subscale of the IAS. Although the

hypotheses were not confirmed, there were a number of significant differences found

between the two groups. Overall, the younger adult sample had consistently higher

scores on most of the measures even though they were matched with the older adult

sample on the WI. The older adult sample had only one significantly higher score than

the younger adult sample, which was on disease fear. The matched younger control

group had significantly higher scores than the older adult group on health anxiety (SHAI

and IAS), hypochondriacal somatic symptoms (SSI, SSAS), frequency of

hypochondriacal thoughts, tendency to experience bodily symptoms as distressing, and

state and trait anxiety, and on the subscales measuring disease conviction, illness

likelihood, body vigilance, fears of illness, hypochondriacal beliefs and disease

conviction, and disruptive effects of symptoms on functioning.

These findings are consistent with findings in the literature on health anxiety in

older adults. Although there is a commonly held belief that older adults display greater

health-related concerns compared with younger adults (Snyder & Stanley, 2001),

researchers have found that older adults do not differ significantly than younger adults

with respect to health anxiety (Barsky, Frank, Cleary, et al., 1991). Bourgault-Fagnou

and Hadjistavropoulos (2009) found that health anxiety among medically frail older

adults was similar to that of younger adults. Those individuals who were less frail had

lower levels of health anxiety than younger adults. Boston and Merrick (2010) similarly

found that the health anxiety scores for a community dwelling older adult group were

193

group on the Bodily Preoccupation subscale of the WI, the Body Vigilance subscale of

the SHAI, and the Disruptive Effects of Symptoms subscale of the IAS. Although the

hypotheses were not confirmed, there were a number of significant differences found

between the two groups. Overall, the younger adult sample had consistently higher

scores on most of the measures even though they were matched with the older adult

sample on the WI. The older adult sample had only one significantly higher score than

the younger adult sample, which was on disease fear. The matched younger control

group had significantly higher scores than the older adult group on health anxiety (SHAI

and IAS), hypochondriacal somatic symptoms (SSI, SSAS), frequency of

hypochondriacal thoughts, tendency to experience bodily symptoms as distressing, and

state and trait anxiety, and on the subscales measuring disease conviction, illness

likelihood, body vigilance, fears of illness, hypochondriacal beliefs and disease

conviction, and disruptive effects of symptoms on functioning.

These findings are consistent with findings in the literature on health anxiety in

older adults. Although there is a commonly held belief that older adults display greater

health-related concerns compared with younger adults (Snyder & Stanley, 2001),

researchers have found that older adults do not differ significantly than younger adults

with respect to health anxiety (Barsky, Frank, Cleary, et al., 1991). Bourgault-Fagnou

and Hadjistavropoulos (2009) found that health anxiety among medically frail older

adults was similar to that of younger adults. Those individuals who were less frail had

lower levels of health anxiety than younger adults. Boston and Merrick (2010) similarly

found that the health anxiety scores for a community dwelling older adult group were

193

similar to those reported in other studies for younger people with chronic illness

(Salkovskis et al., 2002; Rode et al., 2006; Abramowitz et al., 2007). However, although

older adults may report lower levels of anxiety, Snyder and Stanley (2001) suggest that

older patients with hypochondriasis are less functional than younger patients despite

similarities in hypochondriacal symptoms, and that severe health anxiety may be more

incapacitating in older adults even when symptom severity is similar to that of younger

patients. As a result, they may be worried less, but they may have higher levels of

distress and may in fact be engaging in more problematic behaviours to alleviate their

anxiety.

These results also may have been impacted by the dichotomous response options

on the WI. When screening for health anxiety, participants were asked to answer either

"yes" or "no" to the items on the WI. Dichotomous response options have been

respondent-rated as more difficult to use and less suitable for accurately representing

options than Likert scales (Preston & Colman, 2000). This may be particularly relevant

with regards to health anxiety and its contemporary conceptualization as a continuous

construct (Asmundson, Carleton, Bovell, & Taylor, 2008). Thus, the WI may not have

been able to discriminate between a respondent occasionally being fearful of life

threatening illness (e.g., fearful of cancer when a friend or loved one is diagnosed with

the disease) and a respondent who reported being excessively preoccupied with worries

of developing, or fears that they have already developed, a life threatening disease

(Welch, Carleton, & Asmundson, 2009). Although the WI with the "yes/no" format was

given to potential participants because it was rapid and straightforward to administer over

194

similar to those reported in other studies for younger people with chronic illness

(Salkovskis et al., 2002; Rode et al., 2006; Abramowitz et al., 2007). However, although

older adults may report lower levels of anxiety, Snyder and Stanley (2001) suggest that

older patients with hypochondriasis are less functional than younger patients despite

similarities in hypochondriacal symptoms, and that severe health anxiety may be more

incapacitating in older adults even when symptom severity is similar to that of younger

patients. As a result, they may be worried less, but they may have higher levels of

distress and may in fact be engaging in more problematic behaviours to alleviate their

anxiety.

These results also may have been impacted by the dichotomous response options

on the WI. When screening for health anxiety, participants were asked to answer either

"yes" or "no" to the items on the WI. Dichotomous response options have been

respondent-rated as more difficult to use and less suitable for accurately representing

options than Likert scales (Preston & Colman, 2000). This may be particularly relevant

with regards to health anxiety and its contemporary conceptualization as a continuous

construct (Asmundson, Carleton, Bovell, & Taylor, 2008). Thus, the WI may not have

been able to discriminate between a respondent occasionally being fearful of life

threatening illness (e.g., fearful of cancer when a friend or loved one is diagnosed with

the disease) and a respondent who reported being excessively preoccupied with worries

of developing, or fears that they have already developed, a life threatening disease

(Welch, Carleton, & Asmundson, 2009). Although the WI with the "yes/no" format was

given to potential participants because it was rapid and straightforward to administer over

194

the phone, future research in this area may consider using the 5-point Likert scale version

developed by Barsky et al., (1992).

4.4 Contributions

Considering the limited amount of literature with respect to health anxiety in

seniors, this study makes several important contributions. First, this is only study to date

that has evaluated the effectiveness of a CBT program designed specifically for older

adults with health anxiety. Most of the literature on health anxiety does not focus

attention on the concerns of older adults and on the outcome of psychological treatment

in this population. As a result, questions have been raised about the appropriateness of

generalizing psychological interventions for health anxiety developed and tested with

younger adults to seniors (Snyder & Stanley, 2001). Although the results provide mixed

evidence to support the effectiveness of a CBT program with respect to changing

thoughts and behaviours related to health anxiety, the findings from the paired samples t-

tests, analysis of clinically significant change, examination of the maintenance of gains,

supplementary analysis using the WLC group, and qualitative analysis of the post-

treatment responses should be viewed as providing promising evidence in support of

CBT for health anxiety for use with seniors. Participation in such a program is likely to

provide some benefit to seniors with elevated health anxiety.

Second, the treatment protocols used in this study were for six sessions of CBT.

Given the trend toward the use of shorter-term therapies and the limited access that

individuals have to psychological services due to limited resources, research on short-

term therapies provides direction for clinicians working with these patients.

195

the phone, future research in this area may consider using the 5-point Likert scale version

developed by Barsky et al., (1992).

4.4 Contributions

Considering the limited amount of literature with respect to health anxiety in

seniors, this study makes several important contributions. First, this is only study to date

that has evaluated the effectiveness of a CBT program designed specifically for older

adults with health anxiety. Most of the literature on health anxiety does not focus

attention on the concerns of older adults and on the outcome of psychological treatment

in this population. As a result, questions have been raised about the appropriateness of

generalizing psychological interventions for health anxiety developed and tested with

younger adults to seniors (Snyder & Stanley, 2001). Although the results provide mixed

evidence to support the effectiveness of a CBT program with respect to changing

thoughts and behaviours related to health anxiety, the findings from the paired samples t-

tests, analysis of clinically significant change, examination of the maintenance of gains,

supplementary analysis using the WLC group, and qualitative analysis of the post-

treatment responses should be viewed as providing promising evidence in support of

CBT for health anxiety for use with seniors. Participation in such a program is likely to

provide some benefit to seniors with elevated health anxiety.

Second, the treatment protocols used in this study were for six sessions of CBT.

Given the trend toward the use of shorter-term therapies and the limited access that

individuals have to psychological services due to limited resources, research on short-

term therapies provides direction for clinicians working with these patients.

195

Third, the qualitative responses provided further information in support that the

CB model of health anxiety appears to be appropriate for older adults. These findings

provide further support that the thoughts and beliefs of health anxious older adults are

similar among younger and older adults, although further research in this area is needed

to confirm this information empirically. The findings from the qualitative analysis also

suggest that actual illness or disease, rather than worry about the possibility of becoming

ill in the future, may be a greater concern for older adults with health anxiety. Thus,

further research examining the role of health conditions and illness in individuals with

excessive health anxiety appears warranted.

Finally, the comparison of the older adult group and younger adult group

provided further support that younger adults are scoring consistently higher on measures

of health anxiety even when matched by score on a measure of health anxiety (WI)

(Bourgault-Fagnou & Hadjistavropoulos, 2009). However, our older sample of

participants clearly indicated difficulties coping with the reported levels of anxiety.

Given these findings, it is important that clinicians working with these individuals assess

for and address sub-clinical symptoms of health anxiety.

4.5 Limitations

Although this study has advanced the literature on the experience and treatment of

health anxiety, there were several limitations to the present study. First, there were the

difficulties recruiting the intended 31 participants per treatment condition and the need to

settle for a relatively small sample size (n = 57). The difficulty in recruiting the expected

number of participants was the result of several factors. Although we had a number of

196

Third, the qualitative responses provided further information in support that the

CB model of health anxiety appears to be appropriate for older adults. These findings

provide further support that the thoughts and beliefs of health anxious older adults are

similar among younger and older adults, although further research in this area is needed

to confirm this information empirically. The findings from the qualitative analysis also

suggest that actual illness or disease, rather than worry about the possibility of becoming

ill in the future, may be a greater concern for older adults with health anxiety. Thus,

further research examining the role of health conditions and illness in individuals with

excessive health anxiety appears warranted.

Finally, the comparison of the older adult group and younger adult group

provided further support that younger adults are scoring consistently higher on measures

of health anxiety even when matched by score on a measure of health anxiety (WI)

(Bourgault-Fagnou & Hadjistavropoulos, 2009). However, our older sample of

participants clearly indicated difficulties coping with the reported levels of anxiety.

Given these findings, it is important that clinicians working with these individuals assess

for and address sub-clinical symptoms of health anxiety.

4.5 Limitations

Although this study has advanced the literature on the experience and treatment of

health anxiety, there were several limitations to the present study. First, there were the

difficulties recruiting the intended 31 participants per treatment condition and the need to

settle for a relatively small sample size (n = 57). The difficulty in recruiting the expected

number of participants was the result of several factors. Although we had a number of

196

participants indicate their interest in participating in the study and meet criteria for

inclusion in the study, there were a number of participants who declined to participate

prior to enrolment in the study. Many participants indicated they had changed their mind

or did not want to commit to the time involvement. Further, our study required

participants to attend sessions at the University clinic, which, in retrospect, may have

reduced the number of eligible participants due to increased mobility concerns that are

known to be present in older adults. Another difficulty in obtaining the desired sample

size was the limited population that was available. Recruitment for this study occurred

over a 24-month period in a small western Canadian city, and entailed multiple forms of

advertisement (e.g., posters, newspaper advertisements, radio and television appearances,

presentations to seniors' groups) conducted at multiple time points. With successive

recruitment attempts there was a notable decrease in the number of volunteers, suggesting

that the number of potential candidates was dwindling.

Second, is the lack of a long-term follow-up for the WLC group and longer-term

follow-up (e.g., 12 month) for the two treatment groups. We were not able to compare

the WLC condition to the two active treatments at follow-up, which would have been

more informative, given that psychological disorders have been found to improve over

time irrespective of specific treatment (Seivewright et al., 2008) and improvement in

treatment could reflect normal symptom fluctuation (Westen & Morrison, 2001). Though

having the WLC group complete the questionnaires would have allowed us to compare

this group to the two treatment groups, for ethical reasons, we were not comfortable

having participants who were in distress wait for treatment longer than six weeks. In

197

participants indicate their interest in participating in the study and meet criteria for

inclusion in the study, there were a number of participants who declined to participate

prior to enrolment in the study. Many participants indicated they had changed their mind

or did not want to commit to the time involvement. Further, our study required

participants to attend sessions at the University clinic, which, in retrospect, may have

reduced the number of eligible participants due to increased mobility concerns that are

known to be present in older adults. Another difficulty in obtaining the desired sample

size was the limited population that was available. Recruitment for this study occurred

over a 24-month period in a small western Canadian city, and entailed multiple forms of

advertisement (e.g., posters, newspaper advertisements, radio and television appearances,

presentations to seniors' groups) conducted at multiple time points. With successive

recruitment attempts there was a notable decrease in the number of volunteers, suggesting

that the number of potential candidates was dwindling.

Second, is the lack of a long-term follow-up for the WLC group and longer-term

follow-up (e.g., 12 month) for the two treatment groups. We were not able to compare

the WLC condition to the two active treatments at follow-up, which would have been

more informative, given that psychological disorders have been found to improve over

time irrespective of specific treatment (Seivewright et al., 2008) and improvement in

treatment could reflect normal symptom fluctuation (Westen & Morrison, 2001). Though

having the WLC group complete the questionnaires would have allowed us to compare

this group to the two treatment groups, for ethical reasons, we were not comfortable

having participants who were in distress wait for treatment longer than six weeks. In

197

addition, though a longer follow-up is clearly warranted, only a three-month post-

treatment follow-up for the two treatment groups was conducted due to the time

constraints of conducting doctoral research. However, a 12-month follow-up would have

enabled us to evaluate the long-term efficacy of the treatments.

Third, the sample had an unbalanced gender representation. As previously

indicated, 77% of the participants were female. Although this ratio is common in

research with older adults (e.g., Boston & Merrick, 2010; Mohlman & Zinbarg, 2000), it

is important to be aware that these findings may be more applicable to females. Future

research should replicate the current study either using a more gender balanced sample or

a sample exclusively consisting of men.

Fourth, the therapists in this study were relatively inexperienced (i.e., supervised

graduate students in clinical psychology). It is possible that experienced therapists would

have produced more beneficial results for the participants. This possibility remains open

for further study. In addition, there were three therapists providing the interventions, but

the majority of treatment was provided by one main therapist (the author). Specifically,

the main therapist provided treatment to 30 participants, while the other two therapists

provided treatment to eight participants and one participant, respectively. In addition, the

same therapist provided therapy in both the ECBT and SCBT condition. Although this is

beneficial in terms of controlling for therapist differences across conditions, this could

have inadvertently resulted in similarities between the two treatment conditions. Given

these numbers, an examination of the potential effect of therapist could not be conducted.

Future research should ensure each therapist provides treatment to an equal distribution

198

addition, though a longer follow-up is clearly warranted, only a three-month post-

treatment follow-up for the two treatment groups was conducted due to the time

constraints of conducting doctoral research. However, a 12-month follow-up would have

enabled us to evaluate the long-term efficacy of the treatments.

Third, the sample had an unbalanced gender representation. As previously

indicated, 77% of the participants were female. Although this ratio is common in

research with older adults (e.g., Boston & Merrick, 2010; Mohlman & Zinbarg, 2000), it

is important to be aware that these findings may be more applicable to females. Future

research should replicate the current study either using a more gender balanced sample or

a sample exclusively consisting of men.

Fourth, the therapists in this study were relatively inexperienced (i.e., supervised

graduate students in clinical psychology). It is possible that experienced therapists would

have produced more beneficial results for the participants. This possibility remains open

for further study. In addition, there were three therapists providing the interventions, but

the majority of treatment was provided by one main therapist (the author). Specifically,

the main therapist provided treatment to 30 participants, while the other two therapists

provided treatment to eight participants and one participant, respectively. In addition, the

same therapist provided therapy in both the ECBT and SCBT condition. Although this is

beneficial in terms of controlling for therapist differences across conditions, this could

have inadvertently resulted in similarities between the two treatment conditions. Given

these numbers, an examination of the potential effect of therapist could not be conducted.

Future research should ensure each therapist provides treatment to an equal distribution

198

of participants in order to prevent biased treatment results due to the effect of the

therapist rather than due to the program.

Fifth, only self-report measures were included in the design. Aiken (2002)

indicates that individuals may over-report symptoms in order to make their situation seem

worse, or they may under-report the severity or frequency of symptoms in order to

minimize their problems. Unfortunately, there are few practical and well-standardized

indirect and non-reactive measures of the psychological variables of interest in this study.

Future studies may find it informative to examine health care utilization as a more

objective measure of change.

4.6 Future Directions

Given the dearth of literature in the area investigating health anxiety among

seniors, future directions for research are abundant. First, further well-designed trials of

CBT for health anxiety among seniors are required. These studies should include larger

numbers of participants; longer follow-up times; multiple sites; and different treatment

protocols and formats such as treatments that include a greater number of sessions, group

treatments, and in-home sessions for those who are not mobile. It was observed by this

author that a number of participants were interested in and enquired about the possibility

of group therapy.

Although the enhanced components of our CBT program were based on the

literature, the current findings did not support the superiority of ECBT over SCBT.

Further trials should also be designed to assess not only whether the CBT program is

effective, but also which components of the therapy are active for older adults, including

199

of participants in order to prevent biased treatment results due to the effect of the

therapist rather than due to the program.

Fifth, only self-report measures were included in the design. Aiken (2002)

indicates that individuals may over-report symptoms in order to make their situation seem

worse, or they may under-report the severity or frequency of symptoms in order to

minimize their problems. Unfortunately, there are few practical and well-standardized

indirect and non-reactive measures of the psychological variables of interest in this study.

Future studies may find it informative to examine health care utilization as a more

objective measure of change.

4.6 Future Directions

Given the dearth of literature in the area investigating health anxiety among

seniors, future directions for research are abundant. First, further well-designed trials of

CBT for health anxiety among seniors are required. These studies should include larger

numbers of participants; longer follow-up times; multiple sites; and different treatment

protocols and formats such as treatments that include a greater number of sessions, group

treatments, and in-home sessions for those who are not mobile. It was observed by this

author that a number of participants were interested in and enquired about the possibility

of group therapy.

Although the enhanced components of our CBT program were based on the

literature, the current findings did not support the superiority of ECBT over SCBT.

Further trials should also be designed to assess not only whether the CBT program is

effective, but also which components of the therapy are active for older adults, including

199

components of the enhanced therapy. In addition, further research examining ECBT with

older adults from a community mental health setting or psychiatric setting is warranted.

With seniors with lower levels of motivation, more advanced age, or greater disability,

ECBT may prove to be more valuable. The comparison of CBT to other treatment

modalities (e.g., brief dynamic therapy, behaviour therapy) would also be of benefit given

that not all participants responded favourably to CBT.

Further research examining the theoretical model of health anxiety as it applies to

seniors appears warranted. Given our qualitative findings that the CB model of health

anxiety appears to be appropriate for older adults but that our sample had a number of

current health concerns, empirical validation of these findings would help to provide

further insight into the thoughts and beliefs of older adults with elevated health anxiety,

problematic behaviours, and other maintaining factors which could then be specifically

targeted in psychological treatments. The role that health conditions play in elevated

health anxiety among older adults is another area for future research.

Although only a small number (i.e., three) of participants dropped out of

treatment and only two participants indicated in the qualitative questions at post-

treatment that they did not find the treatment helpful, future therapy trials should include

an assessment of treatment acceptability. It would be helpful to know what participants

did not find helpful so that other alternative treatment options could be developed.

Finally, to facilitate healthcare planning and economic evaluation for older adults, future

trials should include an assessment of effect on healthcare resource use.

200

components of the enhanced therapy. In addition, further research examining ECBT with

older adults from a community mental health setting or psychiatric setting is warranted.

With seniors with lower levels of motivation, more advanced age, or greater disability,

ECBT may prove to be more valuable. The comparison of CBT to other treatment

modalities (e.g., brief dynamic therapy, behaviour therapy) would also be of benefit given

that not all participants responded favourably to CBT.

Further research examining the theoretical model of health anxiety as it applies to

seniors appears warranted. Given our qualitative findings that the CB model of health

anxiety appears to be appropriate for older adults but that our sample had a number of

current health concerns, empirical validation of these findings would help to provide

further insight into the thoughts and beliefs of older adults with elevated health anxiety,

problematic behaviours, and other maintaining factors which could then be specifically

targeted in psychological treatments. The role that health conditions play in elevated

health anxiety among older adults is another area for future research.

Although only a small number (i.e., three) of participants dropped out of

treatment and only two participants indicated in the qualitative questions at post-

treatment that they did not find the treatment helpful, future therapy trials should include

an assessment of treatment acceptability. It would be helpful to know what participants

did not find helpful so that other alternative treatment options could be developed.

Finally, to facilitate healthcare planning and economic evaluation for older adults, future

trials should include an assessment of effect on healthcare resource use.

200

4.7 Conclusion

In summary, this study was the first to examine the effectiveness of CBT for

health anxiety among older adults. Although results were mixed, overall, the findings

indicated that CBT is effective for reducing some of the health anxious thoughts and

beliefs in older adults. The results also contributed to the understanding of the

therapeutic relationship, motivation for psychotherapy, and the CB model of health

anxiety as it applies to older adults. Future research is needed to clarify the role of

specific therapy components and their usefulness in alleviating symptoms.

201

4.7 Conclusion

In summary, this study was the first to examine the effectiveness of CBT for

health anxiety among older adults. Although results were mixed, overall, the findings

indicated that CBT is effective for reducing some of the health anxious thoughts and

beliefs in older adults. The results also contributed to the understanding of the

therapeutic relationship, motivation for psychotherapy, and the CB model of health

anxiety as it applies to older adults. Future research is needed to clarify the role of

specific therapy components and their usefulness in alleviating symptoms.

201

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Appendix A

Recruitment Poster

UNIVERSITY OF

4, REGINA

Do You Experience a Lot of Worry About Your Health?

Michelle Bourgault-Fagnou, M.A., & Heather Hadjistavropoulos, Ph.D. from the University of Regina are seeking individuals to participate in a study that is looking to improve the way that worry about health is treated among older adults.

If you are 65 years of age and older and find that you worry a lot about your health, you are eligible to participate. Your participation would involve six weekly individual meetings that last approximately 45 to 60 minutes each and completion of several questionnaires.

Potential benefits of participating in this study include a reduction in worry and negative emotions, improved overall health, and an increased quality of life.

If you would like to participate in this study or would like further information, please call 585-5369.

233

Appendix A

Recruitment Poster

|Sl¥] UNIVERSITY OF

l v REGINA Do You Experience a Lot of Worry

About Your Health?

Michelle Bourgault-Fagnou, M.A., & Heather Hadjistavropoulos, Ph.D. from the University of Regina are seeking individuals to participate in a study that is looking to improve the way that worry about health is treated among older adults.

If you are 65 years of age and older and find that you worry a lot about your health, you are eligible to participate. Your participation would involve six weekly individual meetings that last approximately 45 to 60 minutes each and completion of several questionnaires.

Potential benefits of participating in this study include a reduction in worry and negative emotions, improved overall health, and an increased quality of life.

If you would like to participate in this study or would like further information, please call 585-5369.

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Appendix B

Information Sheet and Consent Form

UNIVERSITY OF

*REGINA [email protected]

Information for Participants

DEPARTMENT OF PSYCHOLOGY Regina, Saskatchewan Canada S4S 0A2 phone: (306) 585-4221 fax: (306) 585-5429 email:

If the page contains any information that is unclear, please ask the researcher for an explanation of the information that is not clear to you.

Title Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors

Background Factors associated with aging may contribute to excessive preoccupation with health-related issues and increased levels of health anxiety. This study is being done to improve the way health anxiety is treated among older adults. A health anxiety treatment program (described below) is being tested to determine if it is effective in helping older adults deal with their health anxiety more effectively.

Procedure This program will involve six weekly individual meetings that last approximately 45 to 60 minutes each. The meetings will take place at the Psychology Training Clinic at the University of Regina. The treatments are based on a programme developed by Barsky & Ahern (2004) which has previously been found to be effective for the treatment of hypochondriasis. Participants will be randomly assigned to one of three groups: (1) Therapy 1, (2) Therapy 2, or (3) waitlist.

Therapy 1 will cover the following: • Education about the nature of health anxiety • Improving your understanding and ability to control your health anxiety using

psychological means (e.g., coping strategies, attention and distraction techniques) • Self-monitoring (i.e., keeping track of your anxiety and methods you use to deal with

it) • Improving the understanding and management of stress • Examination of thoughts and beliefs about health anxiety • Improving behaviours and activities that have an impact on health anxiety

234

Appendix B

Information Sheet and Consent Form

iffl^l UNIVERSITY OF DEPARTMENT OF PSYCHOLOGY

JjfiL REGINA psychology [email protected]

Information for Participants

If the page contains any information that is unclear, please ask the researcher for an explanation of the information that is not clear to you.

Title Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors

Background Factors associated with aging may contribute to excessive preoccupation with health-related issues and increased levels of health anxiety. This study is being done to improve the way health anxiety is treated among older adults. A health anxiety treatment program (described below) is being tested to determine if it is effective in helping older adults deal with their health anxiety more effectively.

Procedure This program will involve six weekly individual meetings that last approximately 45 to 60 minutes each. The meetings will take place at the Psychology Training Clinic at the University of Regina. The treatments are based on a programme developed by Barsky & Ahem (2004) which has previously been found to be effective for the treatment of hypochondriasis. Participants will be randomly assigned to one of three groups: (1) Therapy 1, (2) Therapy 2, or (3) waitlist.

Therapy 1 will cover the following: • Education about the nature of health anxiety • Improving your understanding and ability to control your health anxiety using

psychological means (e.g., coping strategies, attention and distraction techniques) • Self-monitoring (i.e., keeping track of your anxiety and methods you use to deal with

it) • Improving the understanding and management of stress • Examination of thoughts and beliefs about health anxiety • Improving behaviours and activities that have an impact on health anxiety

234

Regina, Saskatchewan Canada S4S 0A2 phone: (306) 585-4221 fax: (306) 585-5429 email:

mailto:[email protected]

■ Improving other emotional states (e.g., depression) that have an impact on health anxiety

■ Maintaining improvements in emotional functioning

Therapy 2 will cover the following: ■ Will contain the same components as Therapy 1 but with added learning and memory

aids (e.g., weekly reading assignments, graphing exercises, expanded reviews of all session material) and instructional videos.

Waitlist Group ■ Participants assigned to the waitlist group will wait up to 12 weeks before beginning

Therapy 2. You will be asked to complete questionnaires about your levels of anxiety and mood (approximately 90 minutes in total), on three different occasions: once when the study begins, once immediately after the study is over, and one final time three months after the treatment program ends. A member of the research team will meet with you to fill out the questionnaires at the Psychology Training Clinic at the University of Regina or at an otherwise convenient location (e.g., your home). In addition, you will be asked to provide information on the relationship with your therapist and motivation for treatment during treatment sessions. Finally, you will be asked to take part in two short interviews, once at the beginning of treatment and once at the end, about your health anxiety, experience with the treatment program, the therapy and motivation for treatment.

Voluntary Participation Participation in this study is voluntary. Should you choose not to participate, or if you wish to withdraw from the study at any time after starting, you may do so without any consequences to your present or future health care.

Confidentiality Only the researchers will know that you are participating in this study. The information and test results obtained in the questionnaires will be stored in locked cabinets or storage rooms. Responses will be coded so that no one knows the identity of clients or caregivers. All responses and test results will be combined into summary data so that it is not possible to identify individual responses. In addition, there are certain limits to confidentiality. For example, if you pose immediate threat to your life or to other individuals, confidentiality may be broken in order to prevent harm. If you disclose information suggesting that any child is at risk of abuse, the Ministry of Social Services will have to be notified. Also, if you become involved in a legal case the judge has the right to subpoena any information relevant to the legal problem.

Possible Benefits & Risks

There are no anticipated risks from your participation. This research may help participants to deal with their health anxiety more effectively in a variety of ways. Further, if the treatment program is judged to be effective, it may help other older adults

235

• Improving other emotional states (e.g., depression) that have an impact on health anxiety

• Maintaining improvements in emotional functioning

Therapy 2 will cover the following: • Will contain the same components as Therapy 1 but with added learning and memory

aids (e.g., weekly reading assignments, graphing exercises, expanded reviews of all session material) and instructional videos.

Waitlist Group • Participants assigned to the waitlist group will wait up to 12 weeks before beginning

Therapy 2. You will be asked to complete questionnaires about your levels of anxiety and mood (approximately 90 minutes in total), on three different occasions: once when the study begins, once immediately after the study is over, and one final time three months after the treatment program ends. A member of the research team will meet with you to fill out the questionnaires at the Psychology Training Clinic at the University of Regina or at an otherwise convenient location (e.g., your home). In addition, you will be asked to provide information on the relationship with your therapist and motivation for treatment during treatment sessions. Finally, you will be asked to take part in two short interviews, once at the beginning of treatment and once at the end, about your health anxiety, experience with the treatment program, the therapy and motivation for treatment.

Voluntary Participation Participation in this study is voluntary. Should you choose not to participate, or if you wish to withdraw from the study at any time after starting, you may do so without any consequences to your present or future health care.

Confidentiality Only the researchers will know that you are participating in this study. The information and test results obtained in the questionnaires will be stored in locked cabinets or storage rooms. Responses will be coded so that no one knows the identity of clients or caregivers. All responses and test results will be combined into summary data so that it is not possible to identify individual responses. In addition, there are certain limits to confidentiality. For example, if you pose immediate threat to your life or to other individuals, confidentiality may be broken in order to prevent harm. If you disclose information suggesting that any child is at risk of abuse, the Ministry of Social Services will have to be notified. Also, if you become involved in a legal case the judge has the right to subpoena any information relevant to the legal problem.

Possible Benefits & Risks There are no anticipated risks from your participation. This research may help participants to deal with their health anxiety more effectively in a variety of ways. Further, if the treatment program is judged to be effective, it may help other older adults

235

who experience health anxiety. A summary of the results will be sent to all interested participants at the end of the study and may take up to one year.

Contact Information and Ethics Approval

If you have questions regarding this study, we encourage you to contact Michelle Bourgault-Fagnou, Department of Psychology, University of Regina, at 585-5369 or by mail at Department of Psychology, University of Regina, Regina, SK, S4S 0A2. You may also contact the Dr. Heather Hadjistavropoulos, Department of Psychology, University of Regina, Regina SK, S4S 0A2 at 585-5133.

This project was approved by the Research Ethics Board, University of Regina. If you have any questions or concerns about your rights or treatment, you can contact the Chair of the Research Ethics Board at 585-4775 or email: research.ethics(&,uregina.ca.

236

who experience health anxiety. A summary of the results will be sent to all interested participants at the end of the study and may take up to one year.

Contact Information and Ethics Approval If you have questions regarding this study, we encourage you to contact Michelle Bourgault-Fagnou, Department of Psychology, University of Regina, at 585-5369 or by mail at Department of Psychology, University of Regina, Regina, SK, S4S 0A2. You may also contact the Dr. Heather Hadjistavropoulos, Department of Psychology, University of Regina, Regina SK, S4S 0A2 at 585-5133.

This project was approved by the Research Ethics Board, University of Regina. If you have any questions or concerns about your rights or treatment, you can contact the Chair of the Research Ethics Board at 585-4775 or email: [email protected].

236


Consent Form

I, , have been informed of the nature of the study

(Print Name) entitled, "Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors," and freely consent to take part. A copy of the form entitled "Information for Potential Participants" and this consent form have been provided to me. I have read the information sheet and understand it.

I understand that my taking part is fully voluntary and that I may decline to take part or withdraw at any time without affecting my current or future health care. I understand that information gained from the study is confidential and may only be shared with members of the research team. I also understand that this information will be used for research purposes and that any details that may reveal my identity will be excluded from study reports and presentations.

• If I have questions I can call the researcher Michelle Bourgault-Fagnou at (306) 585-5369 or call Dr. Heather Hadjistavropoulos at (306) 585-5133.

• I may also contact the Chair of the Research Ethics Board at the University of Regina at (306) 585-4775 or by e-mail: research.ethics uregina.ca.

The content of this consent form has been explained to me and I agree to take part in this study. I have received a copy of this consent form for my records.

Printed Name of Participant:

Signature of Participant:

Signature of Investigator: Date

Your participation is greatly appreciated.

237

Consent Form

I, , have been informed of the nature of the study

(Print Name) entitled, "Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors," and freely consent to take part. A copy of the form entitled "Information for Potential Participants" and this consent form have been provided to me. I have read the information sheet and understand it.

I understand that my taking part is fully voluntary and that I may decline to take part or withdraw at any time without affecting my current or future health care. I understand that information gained from the study is confidential and may only be shared with members of the research team. I also understand that this information will be used for research purposes and that any details that may reveal my identity will be excluded from study reports and presentations.

• If I have questions I can call the researcher Michelle Bourgault-Fagnou at (306) 585-5369 or call Dr. Heather Hadjistavropoulos at (306) 585-5133.

• I may also contact the Chair of the Research Ethics Board at the University of Regina at (306) 585-4775 or by e-mail: research.ethics(5),uregina.ca.

The content of this consent form has been explained to me and I agree to take part in this study. I have received a copy of this consent form for my records.

Printed Name of Participant:

Signature of Participant:

Signature of Investigator: Date

Your participation is greatly appreciated.

237

Appendix C

Outline of Videos

Video 1:

■ Hello, my name is and I have worried a great deal about my health for a

number of years. I had found that since I had gotten older and experienced some

difficulties with my health, my worries about my health had gotten a lot worse. I

found that worrying and feeling anxious took up a lot of my time. Because of this, I

decided to give this approach a try. I've learned a number of ways to cope with my

worry. I've also had to learn how to think differently about my health and bodily

sensations. Overall, I worry a lot less and it has improved my mood and quality of

life. I found that attending all six sessions and trying all the different techniques and

assignments made a big difference in my life.

■ One of the most helpful things I learned in therapy was that I actually had many

beliefs about health that were not correct. These thoughts had a powerful influence

on me. As an example, I used to think "every sensation I had should be able to be

explained by my doctor." I learned in therapy that many bodily sensations actually

have no clear cause, or medical explanation. There are also many symptoms of

chronic conditions that never completely disappear. I was then able to learn several

ways to handle these sensations more effectively.

■ The second belief I had for a very long time was that "somewhere there is a doctor

who can cure my symptoms." I realized that it is much more helpful to change my

goal from finding a cure for many of my body sensations, to learning to live with

238

Appendix C

Outline of Videos

Video 1:

• Hello, my name is and I have worried a great deal about my health for a

number of years. I had found that since I had gotten older and experienced some

difficulties with my health, my worries about my health had gotten a lot worse. I

found that worrying and feeling anxious took up a lot of my time. Because of this, I

decided to give this approach a try. I've learned a number of ways to cope with my

worry. I've also had to learn how to think differently about my health and bodily

sensations. Overall, I worry a lot less and it has improved my mood and quality of

life. I found that attending all six sessions and trying all the different techniques and

assignments made a big difference in my life.

• One of the most helpful things I learned in therapy was that I actually had many

beliefs about health that were not correct. These thoughts had a powerful influence

on me. As an example, I used to think "every sensation I had should be able to be

explained by my doctor." I learned in therapy that many bodily sensations actually

have no clear cause, or medical explanation. There are also many symptoms of

chronic conditions that never completely disappear. I was then able to leam several

ways to handle these sensations more effectively.

• The second belief I had for a very long time was that "somewhere there is a doctor

who can cure my symptoms." I realized that it is much more helpful to change my

goal from finding a cure for many of my body sensations, to learning to live with

238

sensations that doctors have said are not caused by serious illness or they don't know

how to cure. Learning to cope with sensations made me feel like I had control over

my health.

■ Another thought I had that I think is funny now is that "being healthy meant that I

would have no bodily sensations. I used to think that if I did experience different

sensations, they must be symptoms of a disease." During therapy, I learned that

many bodily sensations come from normal bodily changes, such as indigestion, not

having enough sleep, or not having enough exercise. Other sensations come from

stress or strong emotion. The average healthy person has meaningless sensations

every four to six days.

■ By following this approach and learning about how my thoughts make me feel, I

realized the powerful effect that these thoughts have on me. I have learned that it is

okay to have bodily sensations because everybody has them and living with

sensations you don't understand or symptoms from a chronic illness is possible.

Video 2:

■ Hello, my name is , and I have worried a great deal about my health for a

number of years. I have a few health concerns, and because of this, I found myself

always worrying about my health and what my bodily sensations meant. I found that

I sometimes couldn't sleep or I was not able to get as much work done around the

house as I wanted to because I spent a lot of my time worrying and feeling anxious.

■ One of the most helpful things I learned in therapy was that the amount of attention I

pay to my body and different sensations, influences how strong the sensations

239

sensations that doctors have said are not caused by serious illness or they don't know

how to cure. Learning to cope with sensations made me feel like I had control over

my health.

• Another thought I had that I think is funny now is that "being healthy meant that I

would have no bodily sensations. I used to think that if I did experience different

sensations, they must be symptoms of a disease." During therapy, I learned that

many bodily sensations come from normal bodily changes, such as indigestion, not

having enough sleep, or not having enough exercise. Other sensations come from

stress or strong emotion. The average healthy person has meaningless sensations

every four to six days.

• By following this approach and learning about how my thoughts make me feel, I

realized the powerful effect that these thoughts have on me. I have learned that it is

okay to have bodily sensations because everybody has them and living with

sensations you don't understand or symptoms from a chronic illness is possible.

Video 2:

• Hello, my name is , and I have worried a great deal about my health for a

number of years. I have a few health concerns, and because of this, I found myself

always worrying about my health and what my bodily sensations meant. I found that

I sometimes couldn't sleep or I was not able to get as much work done around the

house as I wanted to because I spent a lot of my time worrying and feeling anxious.

• One of the most helpful things I learned in therapy was that the amount of attention I

pay to my body and different sensations, influences how strong the sensations

239

actually feel. I learned that the more attention I give to a sensation, the more it hurt or

bothered me.

■ For example, when I was at home alone, I would often notice and worry about my

back pain and if it actually meant that my condition was getting worse. The pain

would bother me all day long and I would have trouble getting anything done because

the pain was so bad. But then I learned about distraction and how taking part in

activities that are fun can really help me to take my mind off my bodily sensations.

When I play cards in the afternoon with friends or watch a good movie on television,

I hardly notice my pain. I started taking part in more activities that are enjoyable so

that I have less time to think about and notice my bodily sensations.

■ I also found that relaxation such as abdominal breathing was useful for when I was at

home alone and started to worry about my bodily sensations. When I focus on

relaxing, this takes my mind off my bodily sensations. It also helps reduce my

anxiety. Everyday, I try to find about 10 minutes to spend doing the relaxation I

learned in therapy.

Video 3:

■ One of the most important things I learned in therapy was that stress is one of the

main reasons I experience unpleasant bodily sensations.

■ What I learned is that when I am under stress, my body reacts like it needs to get

prepared for an emergency....to run away or fight someone off. For example, if I am

under a lot of stress, I notice that my heart beats faster, my breathing increases, my

240

actually feel. I learned that the more attention I give to a sensation, the more it hurt or

bothered me.

• For example, when I was at home alone, I would often notice and worry about my

back pain and if it actually meant that my condition was getting worse. The pain

would bother me all day long and I would have trouble getting anything done because

the pain was so bad. But then I learned about distraction and how taking part in

activities that are fun can really help me to take my mind off my bodily sensations.

When I play cards in the afternoon with friends or watch a good movie on television,

I hardly notice my pain. I started taking part in more activities that are enjoyable so

that I have less time to think about and notice my bodily sensations.

• I also found that relaxation such as abdominal breathing was useful for when I was at

home alone and started to worry about my bodily sensations. When I focus on

relaxing, this takes my mind off my bodily sensations. It also helps reduce my

anxiety. Everyday, I try to find about 10 minutes to spend doing the relaxation I

learned in therapy.

Video 3:

• One of the most important things I learned in therapy was that stress is one of the

main reasons I experience unpleasant bodily sensations.

• What I learned is that when I am under stress, my body reacts like it needs to get

prepared for an emergency... .to run away or fight someone off. For example, if I am

under a lot of stress, I notice that my heart beats faster, my breathing increases, my

240

muscles feel tight, and my thoughts go a mile a minute. I used to find these

sensations really scary and uncomfortable.

■ The thing I came to realize is that my brain gets ready for an emergency and my body

reacts like this whether there is a true emergency happening or I am just thinking

about something stressful or I am stressed out by little events that are bothering me.

■ For example, when I used to work, I got severe stomach pains and increased heart

rate the moment I stepped into the office every morning. This never happened on the

weekend, unless I started to think about things that had to be done at work.

■ I learned during therapy that stress can be relieved without medications, alcohol, or

quitting all my activities. Instead, I started using the relaxation exercises I used during

therapy to help me relax. I also found that just understanding that these sensations

were brought on when I was feeling under stress, helped me relax.

Video 4:

■ One of the most helpful things I learned in therapy was how to figure out the types of

things that bring on my bodily sensations. It took some thought to figure out which

situations brought on my physical sensations. But once I figured this out, this helped

me figure out how to control my sensations.

■ For example, I noticed that on days where I woke up with stomach pain and I was

under more stress or had an unpleasant meeting scheduled, I was more likely to say to

myself, "Oh no! Now I won't be able to have fun, I'll be feeling terrible all day, and

hopefully this stomach pain isn't something serious, like cancer. Forget even going!"

However, I also noticed that at times where I wasn't under stress, and I woke up with

241

muscles feel tight, and my thoughts go a mile a minute. I used to find these

sensations really scary and uncomfortable.

• The thing I came to realize is that my brain gets ready for an emergency and my body

reacts like this whether there is a tme emergency happening or I am just thinking

about something stressful or I am stressed out by little events that are bothering me.

• For example, when I used to work, I got severe stomach pains and increased heart

rate the moment I stepped into the office every morning. This never happened on the

weekend, unless I started to think about things that had to be done at work.

• I learned during therapy that stress can be relieved without medications, alcohol, or

quitting all my activities. Instead, I started using the relaxation exercises I used during

therapy to help me relax. I also found that just understanding that these sensations

were brought on when I was feeling under stress, helped me relax.

Video 4:

• One of the most helpful things I learned in therapy was how to figure out the types of

things that bring on my bodily sensations. It took some thought to figure out which

situations brought on my physical sensations. But once I figured this out, this helped

me figure out how to control my sensations.

• For example, I noticed that on days where I woke up with stomach pain and I was

under more stress or had an unpleasant meeting scheduled, I was more likely to say to

myself, "Oh no! Now I won't be able to have fun, I'll be feeling terrible all day, and

hopefully this stomach pain isn't something serious, like cancer. Forget even going!"

However, I also noticed that at times where I wasn't under stress, and I woke up with

241

the same kind of pain, I would instead usually say "This will go away as soon as I

have a good breakfast and a walk in the fresh air."

■ By paying attention, I began to notice what made me feel worse and what made me

feel better. So, if I was in a situation that was stressful, I would try relaxation or

distraction to reduce my stress. I would also try to spend more time doing activities

that made me feel good like exercising and spending time with my friends. I now

worry and feel anxious a lot less than I used to.

Video 5:

■ Some of the most helpful things I learned in therapy were different ways for coping

with my upsetting bodily sensations. I learned there are two main things that I can

use to deal with bothersome sensations. The first is making sure I do activities that

are good for my health like exercising and not avoiding these things because they

bring on normal body sensations. The second thing is stopping to do things that

unnecessarily made me anxious.

■ For example, I quit walking because I noticed that I would get completely out of

breath and tired, often worrying that something was really wrong with me. I decided

to begin walking again as a way to exercise and because it was something that I used

to enjoy and hadn't done for a long time. What I did initially was to walk about half

as far as I used to as a way to build up my strength. I really made an effort to take

note of how my sensations felt before and after the walk. I would have to remind

myself that avoiding exercise is more likely the cause of tiredness.

242

the same kind of pain, I would instead usually say "This will go away as soon as I

have a good breakfast and a walk in the fresh air."

• By paying attention, I began to notice what made me feel worse and what made me

feel better. So, if I was in a situation that was stressful, I would try relaxation or

distraction to reduce my stress. I would also try to spend more time doing activities

that made me feel good like exercising and spending time with my friends. I now

worry and feel anxious a lot less than I used to.

Video 5:

• Some of the most helpful things I learned in therapy were different ways for coping

with my upsetting bodily sensations. I learned there are two main things that I can

use to deal with bothersome sensations. The first is making sure I do activities that

are good for my health like exercising and not avoiding these things because they

bring on normal body sensations. The second thing is stopping to do things that

unnecessarily made me anxious.

• For example, I quit walking because I noticed that I would get completely out of

breath and tired, often worrying that something was really wrong with me. I decided

to begin walking again as a way to exercise and because it was something that I used

to enjoy and hadn't done for a long time. What I did initially was to walk about half

as far as I used to as a way to build up my strength. I really made an effort to take

note of how my sensations felt before and after the walk. I would have to remind

myself that avoiding exercise is more likely the cause of tiredness.

242

■ I also learned to stop doing things that made me unnecessarily anxious. For

example, I would often obsessively read medical articles or articles that were related

to health which often made me think I had the disease they were talking about or

would make me worry more about my own problems. I set the goal of not reading

medical articles for one week. What I noticed was that I was thinking less about

medical problems during the week. Now before I start reading a medical article, I

really think about whether it will be helpful to me or if I am just searching to see if I

am sick.

■ Changing these two things were difficult for me... but I think they made the biggest

difference. Instead of reading about being sick, it makes a lot of sense to me to focus

on doing things that are good for me and will help me stay strong and healthy.

Video 6:

• One of the most helpful things I learned in therapy was how my emotions affect my

physical symptoms. I learned that when I feel depressed or anxious, this causes

changes in body. For example, when I get anxious, I often feel it physically in terms

of an increased heart rate, muscle tension, sweating, flushing, dry mouth, stomach

churning, and increased pain. As an anxious person, I am more aware of bodily

sensations, and often have the tendency to believe new and worrisome conditions are

developing. I used to believe these sensations meant that I had a serious medical

problem.

243

• I also learned to stop doing things that made me unnecessarily anxious. For

example, I would often obsessively read medical articles or articles that were related

to health which often made me think I had the disease they were talking about or

would make me worry more about my own problems. I set the goal of not reading

medical articles for one week. What I noticed was that I was thinking less about

medical problems during the week. Now before I start reading a medical article, I

really think about whether it will be helpful to me or if I am just searching to see if I

am sick.

• Changing these two things were difficult for me... but I think they made the biggest

difference. Instead of reading about being sick, it makes a lot of sense to me to focus

on doing things that are good for me and will help me stay strong and healthy.

Video 6:

• One of the most helpful things I learned in therapy was how my emotions affect my

physical symptoms. I learned that when I feel depressed or anxious, this causes

changes in body. For example, when I get anxious, I often feel it physically in terms

of an increased heart rate, muscle tension, sweating, flushing, dry mouth, stomach

churning, and increased pain. As an anxious person, I am more aware of bodily

sensations, and often have the tendency to believe new and worrisome conditions are

developing. I used to believe these sensations meant that I had a serious medical

problem.

243

• I also learned that my mood changes how I think about health and illness. When in a

good mood, I feel like I can handle having an illness. When in a bad mood, however,

I feel like being sick is the worst thing in the world.

■ During therapy, I learned different strategies that I can use to feel better when I am

anxious or mildly depressed. To reduce anxiety, I practice relaxation; do things I

enjoy or postpone worrying until later in the day when I have to really think about

what is bothering me and problem solve. To lift my mild depression, I like going for

walks, being with friends, watching movies, and generally try to focus on positive

things in my life rather than the negative. I make an effort to feel good.

■ Overall, I've found that living with a chronic health problem required an attitude

adjustment on my part. First, I had to accept that my condition may be chronic, and

there are limits to effective treatment. Instead, I have turned my efforts towards

coping with symptoms rather than eliminating them. I have also made a conscious

decision to control the condition as much as possible, rather than letting it control my

life. I now try modifying the situations that make my bodily sensations worse. I have

reduced the stress in my life as much as possible. Another thing I try to do is to

distract my mind from constant worries with relaxation techniques, and pleasurable

activities. And finally, I try to participate in the activities that give me satisfaction as

often as possible, such as spending time with family and friends.

■ I have now realized that having a health problem is not the end of the world and I

now have a number of coping techniques that I can use to deal with problems if they

do arise.

244

• I also learned that my mood changes how I think about health and illness. When in a

good mood, I feel like I can handle having an illness. When in a bad mood, however,

I feel like being sick is the worst thing in the world.

• During therapy, I learned different strategies that I can use to feel better when I am

anxious or mildly depressed. To reduce anxiety, I practice relaxation; do things I

enjoy or postpone worrying until later in the day when I have to really think about

what is bothering me and problem solve. To lift my mild depression, I like going for

walks, being with friends, watching movies, and generally try to focus on positive

things in my life rather than the negative. I make an effort to feel good.

• Overall, I've found that living with a chronic health problem required an attitude

adjustment on my part. First, I had to accept that my condition may be chronic, and

there are limits to effective treatment. Instead, I have turned my efforts towards

coping with symptoms rather than eliminating them. I have also made a conscious

decision to control the condition as much as possible, rather than letting it control my

life. I now try modifying the situations that make my bodily sensations worse. I have

reduced the stress in my life as much as possible. Another thing I try to do is to

distract my mind from constant worries with relaxation techniques, and pleasurable

activities. And finally, I try to participate in the activities that give me satisfaction as

often as possible, such as spending time with family and friends.

• I have now realized that having a health problem is not the end of the world and I

now have a number of coping techniques that I can use to deal with problems if they

do arise.

244

Appendix D

University of Regina Research Ethics Board Approval

LNIVERSIT\ OF

t y REGINA

DATE July 10 2005

TO Michelle Bourgault-Fagnou Psychology

I- kt•t •€4 RA.

mE\IOR,•DL

FROM W Wessel Acting Chair Research Ethics Board

Re. Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors (78S0506)

Please be advised that the University of Regina Research Ethics Board has reviewed your proposal and found it to be

ACCEPTABLE AS SUBMITTED Only applicants with this designation have ethical approval to proceed with their research as descnbed in their applications The Tn-Council Policy Statement on Ethical Conduct for Research Involving Humans requires the researcher to send the Chair of the REB annual reports and notice of project conclusion for research lasting more than one year (Section IF! ETHICAL CLEARANCE MUST BE RENEWED BY SUBMITTING A BRIEF STATUS REPORT EVERY TWELVE MONTHS Clearance will be revoked unless a satisfactory status report is received

2 ACCEPTABLE SUBJECT TO CHANGES AND PRECAUTIONS (SEE ATTACHED) Changes must be submitted to 'he REB and subsequently approved prior to beginning research Pease address 'he concerns raised by the reviewer(s) by means of a supplementary memo to the Chair of the REB Do not submit a new application Please provide the supplementary memorandum** or contact the REB concerning the progress of the project before September 10, 2006 in order to keep your tie active Once changes are deemed acceptable approval will be granted

L.) "1 3 UNACCEPTABLE AS SUBMITTED Please contact the Chair of the REB for advice on how the project proposal might be revised

Dr Warren Wessel

c Dr H Hadistavropoulos supervisor (Psychologyi

KAaatt11.2 CO.

**supplementary memorandum should be 'chive-cad to the Crair of the Research Ethics Board at the Office of Research Services 1AH 505 or by e-ma to research eth cs@uregtha ca

245

Appendix D

University of Regina Research Ethics Board Approval

R E G I N A Mt \ ioR, \Dui

DATE July 10 2005

TO Michelle Bourgault-Fagnou Psychology

FROM W Wessel Acting Chair Research Ethics Board

Re' Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors (78S0506)

Please be advised that the University of Regina Research Ethics Board has reviewed your proposal and found it to be

\Z 1 ACCEPTABLE AS SUBMITTED Only applicants with this designation have ethical approval to proceed with their research as descnbed in their applications The Tn-Counal Policy Statement on Ethical Conduct for Research Involving Humans requires the researcher to send the Chair of the REB annual reports and notice of project conclusion for research lasting more than one year (Section 1 Fi ETHICAL CLEARANCE MUST BE RENEWED BY SUBMITTING A BRIEF STATUS REPORT EVERY TWELVE MONTHS Clearance will be revoked unless a satisfactory status report is 'eceived

Z 2 ACCEPTABLE SUBJECT TO CHANGES AND PRECAUTIONS (SEE ATTACHEDi Changes must be subr-itttec to 'he REB and subsequently approved prior to beginning research P'ease address 'he concerns raised by the reviewer(s) by means of a supplementary memo to the Chair of the REB Do not submit a new application Please provide the supplementary memorandum" or contact the REB concerning the progress of the project before September 10, 2006 in order to keep your fiie active Once changes are deemed acceptable approval will be granted

• 3 UNACCEPTABLE AS SUBMITTED Please contact the Chair of the REB for advice on how the project proposal might be revised

/ < Dr Warren Wessel

c Dr H Hadistavropoulos supervisor (Psychologyi

" supplementary memorandum should be 'orwa-aed to the Crair of the Research Ethics Board at the Office of Research Services |AH 505 or by e-Ta <o researcl et* cs@u'egira ca

245

Sex: ❑ Male ❑ Female / /

(Day/Month/Year) Marital Status: ❑ Single ❑ Common Law ❑ Widowed

Appendix E

Questionnaires

Background Information

Age:

Education: ❑ less than high school ❑ college certificate or some university ❑ Other

Health Conditions: ❑ Alzheimer's Disease ❑ Cancer ❑ Hearing Problems ❑ High Blood Pressure ❑ Liver Disease ❑ Parkinson's Disease ❑ Stroke ❑ Other, please specify

Date of Birth:

❑ Married ❑ Separated/divorced ❑ Other

❑ high school diploma ❑ university degree

❑ Arthritis ❑ Diabetes ❑ Heart Disease ❑ Kidney Disease ❑ Osteoporosis ❑ Respiratory Disease ❑ Vision Problems

List all current medications (and their dosages):

Medication Dosage Times taken per day

246

Appendix E

Questionnaires

Background Information

Sex: • Male • Female Age: Date of Birth: / /

(Day/Month/Year) Marital Status: • Single • Married • Common Law • Separated/divorced • Widowed • Other

Education: a less than high school a high school diploma p college certificate or some university a university degree • Other

Health Conditions: • Alzheimer's Disease p Cancer • Hearing Problems • High Blood Pressure p Liver Disease p Parkinson's Disease p Stroke p Other, please specify

List all current medications (and their dosages):

Medication Dosage Times taken per day

p Arthritis p Diabetes p Heart Disease p Kidney Disease p Osteoporosis p Respiratory Disease p Vision Problems

246

Whiteley Index

Here are some questions about your health. Circle either YES or NO to indicate our answer to each question.

1) Do you often worry about the possibility that you have got a serious illness?

Yes No

2) Are you bothered by many pains and aches? Yes No 3) Do you find that you are often aware of various things happening in your

body? Yes No

4) Do you worry a lot about your health? Yes No 5) Do you often have the symptoms of very serious illness? Yes No 6) If a disease is brought to your attention (through radio, television,

newspapers, or someone you know) do you worry about getting it yourself??

Yes No

7) If you feel ill and someone tells you that you are looking better, do you become annoyed?

Yes No

8) Do you find that you are bothered by many different symptoms? Yes No 9) Is it easy for you to forget about yourself, and think about all sorts of

other things? Yes No

10) Is it hard for you to believe the doctor when he or she tells you there is nothing for you to worry about?

Yes No

11) Do you get the feeling that people are not taking you illness seriously enough?

Yes No

12) Do you think that you worry about your health more than most people? Yes No 13) Do you think there is something seriously wrong with your body? Yes No 14) Are you afraid of illness? Yes No

247

Whiteley Index

Here are some questions about your health. Circle either YES or NO to indicate your answer to each question. ^ ^ _ 1) Do you often worry about the possibility that you have got a serious

illness? 2) Are you bothered by many pains and aches? 3) Do you find that you are often aware of various things happening in your

body? 4) Do you worry a lot about your health? 5) Do you often have the symptoms of very serious illness? 6) If a disease is brought to your attention (through radio, television,

newspapers, or someone you know) do you worry about getting it yourself??

7) If you feel ill and someone tells you that you are looking better, do you become annoyed?

8) Do you find that you are bothered by many different symptoms? 9) Is it easy for you to forget about yourself, and think about all sorts of

other things? 10) Is it hard for you to believe the doctor when he or she tells you there is

nothing for you to worry about? 11) Do you get the feeling that people are not taking you illness seriously

enough? 12) Do you think that you worry about your health more than most people? 13) Do you think there is something seriously wrong with your body? 14) Are you afraid of illness?

Yes

Yes Yes

Yes Yes Yes

Yes

Yes Yes

Yes

Yes

Yes Yes Yes

No

No No

No No No

No

No No

No

No

No No No

247

Health Anxiety Inventory

Instructions: Each question in this section consists of a group of four statements. Please read each group of statements carefully and then select the one which best describes your feelings, over the past week. Identify the statement by ringing the letter next to it, i.e., if you think that statement (a) is correct, ring statement (a); it may be that more than one statement applies, in which case, please ring any that are applicable.

1. (a) I do not worry about my health. (b) I occasionally worry about my health. (c) I spend much of my time worrying about my health. (d) I spend most of my time worrying about my health.

2. (a) I notice aches/pains less than most other people (of my age). (b) I notice aches/pains as much as most other people (of my age). (c) I notice aches/pains more than most other people (of my age). (d) I am aware of aches/pains in my body all the time.

3. (a) As a rule I am not aware of bodily sensations or changes. (b) Sometimes I am aware of bodily sensations or changes. (c) I am often aware of bodily sensations or changes. (d) I am constantly aware of bodily sensations or changes.

4. (a) Resisting thoughts of illness is never a problem. (b) Most of the time I can resist thoughts of illness. (c) I try to resist thoughts of illness but am often unable to do so. (d) Thoughts of illness are so strong that I no longer even try to resist them.

5. (a) As a rule I am not afraid that I have a serious illness. (b) I am sometimes afraid that I have a serious illness. (c) I am often afraid that I have a serious illness. (d) I am always afraid that I have a serious illness.

6. (a) I do not have images (mental pictures) of myself being ill. (b) I occasionally have images of myself being ill. (c) I frequently have images of myself being ill. (d) I constantly have images of myself being ill.

7. (a) I do not have any difficulty taking my mind off thoughts about my health. (b) I sometimes have difficulty taking my mind off thoughts about my health. (c) I often difficulty in taking my mind off thoughts about my health. (d) Nothing can take my mind off thoughts about my health.

248

Health Anxiety Inventory

Instructions: Each question in this section consists of a group of four statements. Please read each group of statements carefully and then select the one which best describes your feelings, over the past week. Identify the statement by ringing the letter next to it, i.e., if you think that statement (a) is correct, ring statement (a); it may be that more than one statement applies, in which case, please ring any that are applicable.

1. (a) I do not worry about my health. (b) I occasionally worry about my health. (c) I spend much of my time worrying about my health. (d) I spend most of my time worrying about my health.

2. (a) I notice aches/pains less than most other people (of my age). (b) I notice aches/pains as much as most other people (of my age). (c) I notice aches/pains more than most other people (of my age). (d) I am aware of aches/pains in my body all the time.

3. (a) As a mle I am not aware of bodily sensations or changes. (b) Sometimes I am aware of bodily sensations or changes. (c) I am often aware of bodily sensations or changes. (d) I am constantly aware of bodily sensations or changes.

4. (a) Resisting thoughts of illness is never a problem. (b) Most of the time I can resist thoughts of illness. (c) I try to resist thoughts of illness but am often unable to do so. (d) Thoughts of illness are so strong that I no longer even try to resist them.

5. (a) As a mle I am not afraid that I have a serious illness. (b) I am sometimes afraid that I have a serious illness. (c) I am often afraid that I have a serious illness. (d) I am always afraid that I have a serious illness.

6. (a) I do not have images (mental pictures) of myself being ill. (b) I occasionally have images of myself being ill. (c) I frequently have images of myself being ill. (d) I constantly have images of myself being ill.

7. (a) I do not have any difficulty taking my mind off thoughts about my health. (b) I sometimes have difficulty taking my mind off thoughts about my health. (c) I often difficulty in taking my mind off thoughts about my health. (d) Nothing can take my mind off thoughts about my health.

248

8. (a) I am lastingly relieved if my doctor tells me there is nothing wrong. (b) I am initially relieved but the worries sometimes return later. (c) I am initially relieved but the worries always return later. (d) I am not relieved if my doctor tells me there is nothing wrong.

9. (a) If I hear about an illness I never think I have it myself. (b) If I hear about an illness I sometimes think that I have it myself. (c) If I hear about an illness I often think I have it myself. (d) If I hear about an illness I always think that I have it myself.

10. (a) If I have a bodily sensation or change I rarely wonder what it means. (b) If I have a bodily sensation or change I often wonder what it means. (c) If I have a bodily sensation or change I always wonder what it means. (d) If I have a bodily sensation or change I must know what it means.

11. (a) I usually feel at very low risk for developing a serious illness. (b) I usually feel at fairly low risk for developing a serious illness. (c) I usually feel at moderate risk for developing a serious illness. (d) I usually feel at high risk for developing a serious illness.

12. (a) I never think that I have a serious illness. (b) I sometimes think that I have a serious illness. (c) I often think that I have a serious illness. (d) I usually think that I have a serious illness.

13. (a) If I notice an unexplained bodily sensation I don't find it difficult to think about other things. (b) If I notice an unexplained bodily sensation I sometimes find it difficult to think about other things. (c) If I notice an unexplained bodily sensation I often find it difficult to think about other things. (d) If I notice an unexplained bodily sensation I always find it difficult to think about other things.

14. (a) My family/friends would say I do not worry enough about my health. (b) My family/friends would say I have a normal attitude about my health. (c) My family/friends would say I worry too much about my health. (d) My family/friends would say I am a hypochondriac.

249

8. (a) I am lastingly relieved if my doctor tells me there is nothing wrong. (b) I am initially relieved but the worries sometimes return later. (c) I am initially relieved but the worries always return later. (d) I am not relieved if my doctor tells me there is nothing wrong.

9. (a) If I hear about an illness I never think I have it myself. (b) If I hear about an illness I sometimes think that I have it myself. (c) If I hear about an illness I often think I have it myself. (d) If I hear about an illness I always think that I have it myself.

10. (a) If I have a bodily sensation or change I rarely wonder what it means. (b) If I have a bodily sensation or change I often wonder what it means. (c) If I have a bodily sensation or change I always wonder what it means. (d) If I have a bodily sensation or change I must know what it means.

11. (a) I usually feel at very low risk for developing a serious illness. (b) I usually feel at fairly low risk for developing a serious illness. (c) I usually feel at moderate risk for developing a serious illness. (d) I usually feel at high risk for developing a serious illness.

12. (a) I never think that I have a serious illness. (b) I sometimes think that I have a serious illness. (c) I often think that I have a serious illness. (d) I usually think that I have a serious illness.

13. (a) If I notice an unexplained bodily sensation I don't find it difficult to think about other things. (b) If I notice an unexplained bodily sensation I sometimes find it difficult to think about other things. (c) If I notice an unexplained bodily sensation I often find it difficult to think about other things. (d) If I notice an unexplained bodily sensation I always find it difficult to think about other things.

14. (a) My family/friends would say I do not worry enough about my health. (b) My family/friends would say I have a normal attitude about my health. (c) My family/friends would say I worry too much about my health. (d) My family/friends would say I am a hypochondriac.

249

For the following questions, please think about what it might be like if you had a serious illness of a type which particularly concerns you (such as heart disease, cancer, multiple sclerosis and so on). Obviously you cannot know for definite what it would be like; please give your best estimate of what you think might happen, basing your estimate on what you know about yourself and serious illness in general.

15. (a) If I had a serious illness I would still be able to enjoy things in my life quite a lot. (b) If I had a serious illness I would still be able to enjoy things in my life a little. (c) If I had a serious illness I would still be almost completely unable to enjoy things in my life. (d) If I had a serious illness I would be completely unable to enjoy life at all.

16. (a) If I developed a serious illness there is a good chance that modern medicine would be able to cure me. (b) If I developed a serious illness there is a moderate chance that modern medicine would be able to cure me. (c) If I developed a serious illness there is a very small chance that modern medicine would be able to cure me. (d) If I developed a serious illness there is no chance that modern medicine would be able to cure me.

17. (a) A serious illness would ruin some aspects of my life. (b) A serious illness would ruin many aspects of my life. (c) A serious illness would ruin almost every aspect of my life. (d) A serious illness would ruin every aspect of my life.

18. (a) If I had a serious illness I would not feel that I had lost my dignity. (b) If I had a serious illness I would feel that I had lost a little of my dignity. (c) If I had a serious illness I would feel that I had lost quite a lot of my dignity. (d) If I had a serious illness I would feel that I had totally lost my dignity.

250

For the following questions, please think about what it might be like if you had a serious illness of a type which particularly concerns you (such as heart disease, cancer, multiple sclerosis and so on). Obviously you cannot know for definite what it would be like; please give your best estimate of what you think might happen, basing your estimate on what you know about yourself and serious illness in general.

15. (a) If I had a serious illness I would still be able to enjoy things in my life quite a lot. (b) If I had a serious illness I would still be able to enjoy things in my life a little. (c) If I had a serious illness I would still be almost completely unable to enjoy things in my life. (d) If I had a serious illness I would be completely unable to enjoy life at all.

16. (a) If I developed a serious illness there is a good chance that modem medicine would be able to cure me. (b) If I developed a serious illness there is a moderate chance that modem medicine would be able to cure me. (c) If I developed a serious illness there is a very small chance that modem medicine would be able to cure me. (d) If I developed a serious illness there is no chance that modem medicine would be able to cure me.

17. (a) A serious illness would ruin some aspects of my life. (b) A serious illness would min many aspects of my life. (c) A serious illness would min almost every aspect of my life. (d) A serious illness would min every aspect of my life.

18. (a) If I had a serious illness I would not feel that I had lost my dignity. (b) If I had a serious illness I would feel that I had lost a little of my dignity. (c) If I had a serious illness I would feel that I had lost quite a lot of my dignity. (d) If I had a serious illness I would feel that I had totally lost my dignity.

250

SSAS

Please indicate the degree to which each of the following statements are true of you in general. Circle your answer.

...;\ ,----

N,.

Not-at all true

A little , obit true

-.. \

Moderately true

Quite a bit true

A great i deal '

true 1. I can't stand smoke,

smog, or pollutants in the air.

1 2 3 4 5

2. I am often aware of various things happening within my body.

1 2 3 4 5

3. When I bruise myself, it stays noticeable for a long time.

1 2 3 4 5

4. I sometimes can feel the blood flowing in my body.

1 2 3 4 5

5. Sudden loud noises really bother me.

1 2 3 4 5

6. I can sometimes hear my pulse or my heartbeat throbbing in my ear.

1 2 3 4 5

7. I hate to be too hot or too cold.

1 2 3 4 5

8. I am quick to sense the hunger contractions in my stomach.

1 2 3 4 5

9. Even something minor, like an insect bite or a splinter, really bothers me.

1 2 3 4 5

10. I can't stand pain. 1 2 3 4 5

251

SSAS

Please indicate the degree to which each of the following statements are true of you in general. Circle your answer.

"W5? "•> 5^" ^..-7„, „™w™.

. ^Safex i.., ...

1. I can't stand smoke, smog, or pollutants in the air.

2. I am often aware of various things happening within my body.

3. When I bruise myself, it stays noticeable for a long time.

4. I sometimes can feel the blood flowing in my body.

5. Sudden loud noises really bother me.

6. I can sometimes hear my pulse or my heartbeat throbbing in my ear.

7. I hate to be too hot or too cold.

8. I am quick to sense the hunger contractions in my stomach.

9. Even something minor, like an insect bite or a splinter, really bothers me.

10. I can't stand pain.

aUtrwe

2

2

2

2

2

2

2

2

2

2

Moderately trite

3

3

3

3

3

3

3

3

3

3

Quite a WNrtie

4

4

4

4

4

4

4

4

4

4

A grist k 4#al s

true 5

5

5

5

5

5

5

5

5

5

251

S.S.I.

Below is a list of symptoms. For each one, please circle the number indicating how much it has bothered you over the past 6 months.

N\ - ,

1. Not it w

all ' A little

bit Moderately Quite *,

bit A great

deal 1. Nausea or vomiting 1 2 3 4 5 2. Soreness in your muscles 1 2 3 4 5 3. Pains or cramps in your

abdomen 1 2 3 4 5

4. Feeling faint or dizzy 1 2 3 4 5 5. Trouble with your vision 1 2 3 4 5 6. Your muscles twitching

or jumping 1 2 3 4 5

7. Feeling fatigued, weak, or tired all over

1 2 3 4 5

8. A fullness in your head or nose

1 2 3 4 5

9. Pains in your lower back 1 2 3 4 5 10. Constipation 1 2 3 4 5 11. Trouble catching your

breath 1 2 3 4 5

12. Hot or cold spells 1 2 3 4 5 13. A ringing or buzzing in

your ears 1 2 3 4 5

252

S.S.I.

Below is a list of symptoms. For each one, please circle the number indicating how much it has bothered you over the past 6 months.

mjmagjSj *N s \ *A

. . 9 **>: 1 \ , . 1. Nausea or vomiting 2. Soreness in your muscles 3. Pains or cramps in your

abdomen 4. Feeling faint or dizzy 5. Trouble with your vision 6. Your muscles twitching

or jumping 7. Feeling fatigued, weak,

or tired all over 8. A fullness in your head

or nose 9. Pains in your lower back 10. Constipation 11. Trouble catching your

breath 12. Hot or cold spells 13. A ringing or buzzing in

your ears

IVnt itt A ttftt , Wt

2 2 2

2 2 2

2

2

2 2 2

2 2

Moderately \ v.

3 3 3

3 3 3

3

3

3 3 3

3 3

Qu i t e*

4 4 4

4 4 4

4

4

4 4 4

4 4

Agre^tr

5 5 5

5 5 5

5

5

5 5 5

5 5

252

HCQ

Below are some thoughts or ideas that may go through your mind when you are nervous or when you become concerned about your health. Indicate how often each thought occurs by rating each thought from 1-5 using the scale below. Write your answer in the blank provided. 1= Thought never occurs 2 = Thought rarely occurs 3 = Thought occurs during half of the times when I am nervous or concerned 4 = Thought usually occurs 5 = Thought always occurs

I must have a brain tumor I am having a heart attack I am going to have a stroke I am about to die I have a serious brain disease My breathing is going to fail I have cancer I have a heart condition These symptoms are getting worse

253

I have a fatal illness I have AIDS I have a muscle wasting disease I have multiple sclerosis I have leukemia I have a lung disease I have a brain hemorrhage I have a serious infection I have a serious physical illness

HCQ

Below are some thoughts or ideas that may go through your mind when you are nervous or when you become concerned about your health. Indicate how often each thought occurs by rating each thought from 1-5 using the scale below. Write your answer in the blank provided. 1 = Thought never occurs 2 = Thought rarely occurs 3 = Thought occurs during half of the times when I am nervous or concerned 4 = Thought usually occurs 5 = Thought always occurs

I must have a brain tumor I am having a heart attack I am going to have a stroke I am about to die I have a serious brain disease My breathing is going to fail I have cancer I have a heart condition These symptoms are getting worse

I have a fatal illness _I have AIDS I have a muscle wasting disease I have multiple sclerosis I have leukemia I have a lung disease I have a brain hemorrhage I have a serious infection I have a serious physical illness

253


Instructions: Circle the one number that best represents the extent to which you agree with the item. If any of the items concern something that is not part of your experience (e.g., "it scares me when I feel shaky" for someone who has never trembled or had the "shakes"), answer on the basis of how you might feel if you had such an experience. Otherwise, answer all the items on the basis of your own experience.

--‘ . , Ver

Little eA Little Some Much

Very Much

1. It is important to me not to appear nervous. 1 2 3 4 5

2. When I cannot keep my mind on a task, I worry that I might be going crazy. 1 2 3 4 5

3. It scares me when I feel "shaky" (trembling). 1 2 3 4 5

4. It scares me when I feel faint. 1 2 3 4 5

5. It is important to me to stay in control of my emotions. 1 2 3 4 5

6. It scares me when my heart beats rapidly. 1 2 3 4 5

7. It embarrasses me when my stomach growls. 1 2 3 4 5

8. It scares me when I am nauseous. 1 2 3 4 5

9. When I notice that my heart is beating rapidly, I worry that I might have a heart attack.

1 2 3 4 5

10. It scares me when I become short of breath. 1 2 3 4 5

11. When my stomach is upset, I worry that I might be seriously ill. 1 2 3 4 5

12. It scares me when I am unable to keep my mind on a task. 1 2 3 4 5

13. Other people notice when I feel shaky. 1 2 3 4 5

254


Instructions: Circle the one number that best represents the extent to which you agree with the item. If any of the items concern something that is not part of your experience (e.g., "it scares me when I feel shaky" for someone who has never trembled or had the "shakes"), answer on the basis of how you might feel if you had such an experience. Otherwise, answer all the items on the basis of your own experience.

1. It is important to me not to appear nervous.

2. When I cannot keep my mind on a task, I worry that I might be going crazy.

3. It scares me when I feel "shaky" (trembling).

4. It scares me when I feel faint.

5. It is important to me to stay in control of my emotions.

6. It scares me when my heart beats rapidly.

7. It embarrasses me when my stomach growls.

8. It scares me when I am nauseous.

9. When I notice that my heart is beating rapidly, I worry that I might have a heart attack.

10. It scares me when I become short of breath.

11. When my stomach is upset, I worry that I might be seriously ill.

12. It scares me when I am unable to keep my mind on a task.

13. Other people notice when I feel shaky.

Little

1

1

1

1

1

1

1

1

1

1

1

1

1

A Little

2

2

2

2

2

2

2

2

2

2

2

2

2

Some

3

3

3

3

3

3

3

3

3

3

3

3

3

Much

4

4

4

4

4

4

4

4

4

4

4

4

4

Very •Much

5

5

5

5

5

5

5

5

5

5

5

5

5

254

14. Unusual body sensations scare me. 1 2 3 4 5

15. When I am nervous, I worry that I might be mentally ill. 1 2 3 4 5

16. It scares me when I am nervous. 1 2 3 4 5

255

14. Unusual body sensations scare me.

15. When I am nervous, I worry that I might be mentally ill.

16. It scares me when I am nervous.

1

1

1

2

2

2

3

3

3

4

4

4

5

5

5

255

State-Trait Anxiety Inventory — State (Form Y; STAI-S)

Directions: A number of statements which people have used to describe themselves are given below. Read each statement and then circle the appropriate number to the right of the statement to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your present feelings best.

• . , ,,, , - ,,,

" , •

Not at -All

Somewhpt Moderately so

Very Much

SO ' 1. I feel calm 1 2 3 4

2. I feel secure 1 2 3 4

3. I am tense 1 2 3 4

4. I feel strained 1 2 3 4 5. I feel at ease 1 2 3 4

6. I feel upset 1 2 3 4

7. I am presently worrying over possible misfortunes

1 2 3 4

8. I feel satisfied 1 2 3 4 9. I feel frightened 1 2 3 4 10. I am comfortable 1 2 3 4

11. I feel self-confident 1 2 3 4

12. I feel nervous 1 2 3 4

13. I am jittery 1 2 3 4

14. I feel indecisive 1 2 3 4

15. I am relaxed 1 2 3 4

16. I feel content 1 2 3 4

17. I am worried 1 2 3 4

18. I feel confused 1 2 3 4 19. I feel steady 1 2 3 4 20. I feel pleasant 1 2 3 4

256

State-Trait Anxiety Inventory - State (Form Y; STAI-S)

Directions: A number of statements which people have used to describe themselves are given below. Read each statement and then circle the appropriate number to the right of the statement to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your present feelings best.

1.

2.

3.

4. 5.

6.

7.

8. 9. 10. 11.

12.

13.

14.

15.

16.

17.

18. 19. 20.

I feel calm

I feel secure

I am tense

I feel strained I feel at ease

I feel upset

I am presently worrying over possible misfortunes I feel satisfied I feel frightened I am comfortable I feel self-confident

I feel nervous

I am jittery

I feel indecisive

I am relaxed

I feel content

I am worried

I feel confused I feel steady I feel pleasant

Not at All

Somewhat

2

2

2 2 2 2

2

2 2 2 2

2

2

2

2

2

2

2 2 2

' 'so • *-; 3

3

3 3 3 3

3

3 3 3 3

3

3

3

3

3

3

3 3 3

4

4

4 4 4 4

4

4 4 4 4

4

4

4

4

4

4

4 4 4

256

State-Trait Anxiety Inventory — Trait (Form Y; STAI-T)

Instructions: A number of statements which people have used to describe themselves are given below. Read each statement and then circle the appropriate number to the right of the statement to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer that seems to describe how you generally feel.

Almost Never Sometimes Often

Almost ,-, Always

21. I feel pleasant 1 2 3 4

22. I feel nervous and restless 1 2 3 4

23. I feel satisfied with myself 1 2 3 4

24. I wish I could be as happy as others seem to be 1 2 3 4

25. I feel like a failure 1 2 3 4

26. I feel rested 1 2 3 4

27. I am "calm, cool, and collected" 1 2 3 4

28. I feel that difficulties are piling up so that I cannot overcome them 1 2 3 4

29. I worry too much over something that really doesn't matter

1 2 3 4

30. I am happy 1 2 3 4 31. I have disturbing thoughts 1 2 3 4

32. I lack self-confidence 1 2 3 4

33. I feel secure 1 2 3 4

34. I make decisions easily 1 2 3 4

35. I feel inadequate 1 2 3 4

36. I am content 1 2 3 4

37. Some unimportant thoughts run through my mind and bothers me 1 2 3 4

38. I take disappointments so keenly that I can't put them out of my mind 1 2 3 4

39. I am a steady person 1 2 3 4

40. I get in a state of tension or turmoil as I think over my recent concerns and interests

1 2 3 4

257

State-Trait Anxiety Inventory - Trait (Form Y; STAI-T)

Instructions: A number of statements which people have used to describe themselves are given below. Read each statement and then circle the appropriate number to the right of the statement to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer that seems to describe how you generally feel.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30. 31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

I feel pleasant

I feel nervous and restless

I feel satisfied with myself

I wish I could be as happy as others seem to be I feel like a failure

I feel rested

I am "calm, cool, and collected"

I feel that difficulties are piling up so that I cannot overcome them I worry too much over something that really doesn't matter I am happy I have disturbing thoughts

I lack self-confidence

I feel secure

I make decisions easily

I feel inadequate

I am content

Some unimportant thoughts run through my mind and bothers me

I take disappointments so keenly that I can't put them out of my mind

I am a steady person

I get in a state of tension or turmoil as I think over my recent concerns and interests

Almost Newr,

1

Sometimes 2

2

2

2 2 2

2

2 2

2 2

2

2

2

2

2

2

2

2

2

Often 3

3

3

3 3 3

3

3 3

3 3

3

3

3

3

3

3

3

3

3

Almost Always *.

4

4

4

4 4 4

4

4 4

4 4

4

4

4

4

4

4

4

4

4

257

Mood Assessment Scale

Instructions: Choose the best answer for how you have felt over the past week:

1) Are you basically satisfied with your life? Yes No 2) Have you dropped many of your activities and interests? Yes No 3) Do you feel that your life is empty? Yes No 4) Do you often get bored? Yes No 5) Are you hopeful about the future? Yes No 6) Are you bothered by thoughts you can t get out of your head? Yes No 7) Are you in good spirits most of the time? Yes No 8) Are you afraid that something bad is going to happen to you? Yes No 9) Do you feel happy most of the time? Yes No 10) Do you often feel helpless? Yes No 11) Do you often get restless and fidgety? Yes No 12) Do you prefer to stay at home, rather than going out and doing new

things? Yes No

13) Do you frequently worry about the future? Yes No 14) Do you feel you have more problems with memory than most? Yes No 15) Do you think it is wonderful to be alive now? Yes No 16) Do you often feel downhearted and blue? Yes No 17) Do you feel pretty worthless the way you are now? Yes No 18) Do you worry a lot about the past? Yes No 19) Do you find life very exciting? Yes No 20) Is it hard for you to get started on new projects? Yes No 21) Do you feel full of energy? Yes No 22) Do you feel that your situation is hopeless? Yes No 23) Do you think that most people are better off than you are? Yes No 24) Do you frequently get upset over little things? Yes No 25) Do you frequently feel like crying? Yes No 26) Do you have trouble concentrating? Yes No 27) Do you enjoy getting up in the morning? Yes No 28) Do you prefer to avoid social gatherings? Yes No 29) Is it easy for you to make decisions? Yes No 30) Is your mind as clear as it used to be? Yes No

258

Mood Assessment Scale

Instructions: Choose the best answer for how you have felt over the past week:

1) Are you basically satisfied with your life? 2) Have you dropped many of your activities and interests? 3) Do you feel that your life is empty? 4) Do you often get bored? 5) Are you hopeful about the future? 6) Are you bothered by thoughts you can t get out of your head? 7) Are you in good spirits most of the time? 8) Are you afraid that something bad is going to happen to you? 9) Do you feel happy most of the time? 10) Do you often feel helpless? 11) Do you often get restless and fidgety? 12) Do you prefer to stay at home, rather than going out and doing new

things? 13) Do you frequently worry about the future? 14) Do you feel you have more problems with memory than most? 15) Do you think it is wonderful to be alive now? 16) Do you often feel downhearted and blue? 17) Do you feel pretty worthless the way you are now? 18) Do you worry a lot about the past? 19) Do you find life very exciting? 20) Is it hard for you to get started on new projects? 21) Do you feel full of energy? 22) Do you feel that your situation is hopeless? 23) Do you think that most people are better off than you are? 24) Do you frequently get upset over little things? 25) Do you frequently feel like crying? 26) Do you have trouble concentrating? 27) Do you enjoy getting up in the morning? 28) Do you prefer to avoid social gatherings? 29) Is it easy for you to make decisions? 30) Is your mind as clear as it used to be?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

No No No No No No No No No No No No No No No No No No

258


Instructions: Please answer each question.

1) Do you or would you have pain with vigorous activities such as Yes No running, lifting heavy objects or participating in strenuous sports?

2) Do you or would you have pain with moderate activities such as Yes No moving a heavy table, pushing a vacuum cleaner, bowling or playing golf?

3) Do you or would you have pain with lifting or carrying groceries? Yes No 4) Do you or would you have pain climbing more than one flight of Yes No

stairs? 5) Do you or would you have pain climbing only a few steps? Yes No 6) Do you or would you have pain walking more than one block? Yes No 7) Do you or would you have pain walking one block or less? Yes No 8) Do you have pain with bathing or dressing? Yes No 9) Have you cut down the amount of time you spend on work or other

activities because of pain? Yes No

10) Have you been accomplishing less than you would like to because Yes No of pain?

11) Have you limited the kind of work or other activities you do because of pain?

Yes No

12) Does the work or activities you do require extra effort because of Yes No pain?

13) Do you have trouble sleeping because of pain? Yes No 14) Does pain prevent you from attending religious activities? Yes No 15) Does pain prevent you from enjoying any other social or Yes No

recreational activities (other than religious services)? 16) Does or would pain prevent you from traveling or using standard Yes No

transportation? 17) Does pain make you feel fatigued or tired? Yes No 18) Do you have to rely on family members or friends for help because Yes No

of pain? 19) On a scale of zero to ten, with zero meaning no pain, and ten

meaning the worst pain you can imagine, how severe is your pain today?

0 1 2 3 4 5 6 7 8 9 10 (0-10)

20) In the last seven days, on a scale of zero to ten, with zero meaning no pain, and ten meaning the worst pain you can imagine, how severe has your pain been on average?

0 1 2 3 4 5 6 7 8 9 10 (0-10)

259


Instructions: Please answer each question.

1) Do you or would you have pain with vigorous activities such as running, lifting heavy objects or participating in strenuous sports?

2) Do you or would you have pain with moderate activities such as moving a heavy table, pushing a vacuum cleaner, bowling or playing golf?

3) Do you or would you have pain with lifting or carrying groceries? 4) Do you or would you have pain climbing more than one flight of

stairs? 5) Do you or would you have pain climbing only a few steps? 6) Do you or would you have pain walking more than one block? 7) Do you or would you have pain walking one block or less? 8) Do you have pain with bathing or dressing? 9) Have you cut down the amount of time you spend on work or other

activities because of pain? 10) Have you been accomplishing less than you would like to because

of pain? 11) Have you limited the kind of work or other activities you do

because of pain? 12) Does the work or activities you do require extra effort because of

pain? 13) Do you have trouble sleeping because of pain? 14) Does pain prevent you from attending religious activities? 15) Does pain prevent you from enjoying any other social or

recreational activities (other than religious services)? 16) Does or would pain prevent you from traveling or using standard

transportation? 17) Does pain make you feel fatigued or tired? 18) Do you have to rely on family members or friends for help because

of pain? 19) On a scale of zero to ten, with zero meaning no pain, and ten

meaning the worst pain you can imagine, how severe is your pain today?

0 1 2 3 4 5 6 7 8 9 10

20) In the last seven days, on a scale of zero to ten, with zero meaning no pain, and ten meaning the worst pain you can imagine, how severe has vour pain been on average?

0 1 2 3 4 5 6 7 8 9 10

Yes

Yes

Yes Yes

Yes Yes Yes Yes Yes

Yes

Yes

Yes

Yes Yes Yes

Yes

Yes Yes

No

No

No No

No No No No No

No

No

No

No No No

No

No No

(0-10)

(0-10)

259

21) Do you have pain that never completely goes away? Yes No 22) Do you have pain every day? Yes No 23) Do you have pain several times a week? Yes No 24) Over the last seven days, has pain caused you to feel sad or Yes No

depressed?

260

21) Do you have pain that never completely goes away? 22) Do you have pain every day? 23) Do you have pain several times a week? 24) Over the last seven days, has pain caused you to feel sad or

depressed?

Yes Yes Yes Yes

No No No No

260

SF-12

The SF-12 is copy-righted so was not included here.

261

SF-12

The SF-12 is copy-righted so was not included here.

261

Working Alliance Inventory — Client Form

Below there are sentences that describe some of the different ways a person might think or feel about his or her therapist (counselor). If the statement describes the way you always feel (or think) circle the number 7; if it never applies to you circle the number 1. Use the number in between to describe the variations between these extremes.

Work fast, your first impressions are the ones we would like to see. (PLEASE DON'T FORGET TO RESPOND TO EVERY ITEM.)

1. I feel uncomfortable with my therapist. 1 2 3 4 5 6 7

Never Rarely Occasionally Sometimes Often Very Always Often

2. My therapist and I agree about the things I will need to do in therapy to help improve my situation. 1 2 3 4 5 6 7


3. I am worried about the outcome of these sessions. 1 2 3 4 5 6 7


4. What I am doing in therapy gives me new ways of looking at my problems. 1 2 3 4 5 6 7


5. My therapist and I understand each other. 1 2 3 4 5 6 7


6. My therapist perceives accurately what my goals are. 1 2 3 4 5 6 7


262

Working Alliance Inventory - Client Form

Below there are sentences that describe some of the different ways a person might think or feel about his or her therapist (counselor). If the statement describes the way you always feel (or think) circle the number 7; if it never applies to you circle the number 1. Use the number in between to describe the variations between these extremes.

Work fast, your first impressions are the ones we would like to see. (PLEASE DON'T FORGET TO RESPOND TO EVERY ITEM.)

1. I feel uncomfortable with my therapist. 1 2 3 4 5 6 7


2. My therapist and I agree about the things I will need to do in therapy to help improve my situation. 1 2 3 4 5 6 7


3. I am worried about the outcome of these sessions. 1 2 3 4 5 6 7


4. What I am doing in therapy gives me new ways of looking at my problems. 1 2 3 4 5 6 7


5. My therapist and I understand each other. 1 2 3 4 5 6 7


6. My therapist perceives accurately what my goals are. 1 2 3 4 5 6 7


262

7. I find what I am doing in therapy confusing. 1 2 3 4 5 6 7


8. I believe my therapist likes me. 1 2 3 4 5 6 7


9. I wish my therapist and I could clarify the purpose of our sessions. 1 2 3 4 5 6 7


10. I disagree with my therapist about what I ought to get out of therapy. 1 2 3 4 5 6 7


11. I believe the time my therapist and I are spending together is not spent efficiently. 1 2 3 4 5 6 7


12. My therapist does not understand what I am trying to accomplish in therapy. 1 2 3 4 5 6 7


13. I am clear on what my responsibilities are in therapy. 1 2 3 4 5 6 7


14. The goals of these sessions are important to me. 1 2 3 4 5 6 7


15. I find what my therapist and I are doing in sessions is unrelated to my concerns. 1 2 3 4 5 6 7


263

7. I find what I am doing in therapy confusing. 1 2 3 4

Never Rarely Occasionally Sometimes 5

Often 6

Very Often

7 Always

8. I believe my therapist likes me. 1 2 3 4

Never Rarely Occasionally Sometimes

9. I wish my therapist and I could clarify the purpose 1 2 3 4


10.1 disagree with my therapist about what I ought to 1 2 3 4


11.1 believe the time my therapist and I are spending 1 1 2 3 4


12. My therapist does not understand what I am trying 1 2 3 4


5 Often

6 Very Often

of our sessions. 5

Often 6

Very Often

get out of therapy. 5

Often

:ogether is 5

Often

6 Very Often

7 Always

7 Always

7 Always

not spent efficiently. 6

Very Often

to accomplish in therapy 5

Often 6

Very Often

7 Always

7 Always

13.1 am clear on what my responsibilities are in therapy. 1 2 3 4


Often 6

Very Often

7 Always

14. The goals of these sessions are important to me. 1 2 3 4


Often 6

Very Often

7 Always

15.1 find what my therapist and I are doing in sessions is unrelated to my concerns. 1 2 3 4


Often 6

Very Often

7 Always

263

16. I feel the things I do in therapy will help me to accomplish the changes I want. 1 2 3 4


Often 6

Very Often

7 Always

17. I believe my therapist is genuinely concerned for my welfare. 1 2 3 4


Often 6

Very Often

7 Always

18. I am clear as to what my therapist wants me to do in these sessions. 1 2 3 4


Often 6

Very Often

7 Always

19. My therapist and I respect each another. 1 2 3 4


Often 6

Very Often

7 Always

20. I feel that my therapist is not totally honest about his/her feelings towards me. 1 2 3 4


Often 6

Very Often

7 Always

21. I am confident in my therapist's ability to help me. 1 2 3 4


Often 6

Very Often

7 Always

22. My therapist and I are working towards mutually agreed upon goals. 1 2 3 4


Often 6

Very Often

7 Always

23. I feel that my therapist appreciates me. 1 2 3 4


Often 6

Very Often

7 Always

264

16.1 feel the things I do in therapy will help me to accomplish the changes I want. 1 2 3 4 5 6 7


17.1 believe my therapist is genuinely concerned for my welfare. 1 2 3 4 5 6 7


18.1 am clear as to what my therapist wants me to do in these sessions. 1 2 3 4 5 6 7


19. My therapist and I respect each another. 1 2 3 4 5 6 7


20.1 feel that my therapist is not totally honest about his/her feelings towards me. 1 2 3 4 5 6 7


21.1 am confident in my therapist's ability to help me. 1 2 3 4 5 6 7


22. My therapist and I are working towards mutually agreed upon goals. 1 2 3 4 5 6 7


23.1 feel that my therapist appreciates me. 1 2 3 4 5 6 7


264

24. We agree on what is important for me to work on. 1 2 3

Never Rarely Occasionally 4

Sometimes 5

Often 6

Very Often

7 Always

25. As a result of these sessions, I am clearer as to how I might be able to change. 1 2 3


Sometimes 5

Often 6

Very Often

7 Always

26. My therapist and I trust one another. 1 2 3


Sometimes 5

Often 6

Very Often

7 Always

27. My therapist and I have different ideas on what my problems are. 1 2 3


Sometimes 5

Often 6

Very Often

7 Always

28. My relationship with my therapist is very important to me. 1 2 3


Sometimes 5

Often 6

Very Often

7 Always

29. I have the feeling that if I say or do the wrong things my therapist will stop working with me. 1 2 3 4 5 6 7


30. My therapist and I collaborate on setting goals for my therapy. 1 2 3 4 5 6 7


31. I am frustrated by the things I am doing in therapy. 1 2 3 4 5 6 7


265

24. We agree on what is important for me to work on. 1 2 3 4 5 6 7


25. As a result of these sessions, I am clearer as to how I might be able to change. 1 2 3 4 5 6 7


26. My therapist and I trust one another. 1 2 3 4 5 6 7


27. My therapist and I have different ideas on what my problems are. 1 2 3 4 5 6 7


28. My relationship with my therapist is very important to me. 1 2 3 4 5 6 7


29.1 have the feeling that if I say or do the wrong things my therapist will stop working with me. 1 2 3 4 5 6 7


30. My therapist and I collaborate on setting goals for my therapy. 1 2 3 4 5 6 7


31.1 am frustrated by the things I am doing in therapy. 1 2 3 4 5 6 7


265

32. We have established a good understanding of the kinds of changes that would be good for me. 1 2 3 4 5 6 7


33. The things that my therapist is asking me to do don't make sense. 1 2 3 4 5 6 7


34. I don't know what to expect as a result of therapy. 1 2 3 4 5 6 7


35. I believe the way we are working with my problem is correct. 1 2 3 4 5 6 7


36. I feel my therapist cares about me even when I do things that he/she does no approve of. 1 2 3 4 5 6 7


266

32. We have established a good xmderstanding of the kinds of chang good for me. 1 2 3 4 5

Never Rarely Occasionally Sometimes Often

;es that would be

6 Very Often

7 Always

33. The things that my therapist is asking me to do don't make sense. 1 2 3 4 5

Never Rarely Occasionally Sometimes Often 6

Very Often

7 Always

34.1 don't know what to expect as a result of therapy. 1 2 3 4 5


Very Often

7 Always

35.1 believe the way we are working with my problem is correct. 1 2 3 4 5


Very Often

36.1 feel my therapist cares about me even when I do things that he/she does of. 1 2 3 4 5


Very Often

7 Always

no approve

7 Always

266

NML-2

Rate the extent to which each statement applies to you on a 6-point scale, ranging from 1, "not at all applicable" to 6, "very applicable".

to,,,,_,N. w , ,,

Not at all applicable -

Wry appiic le

6 1. My problems make me profoundly unhappy.

1 2 3 4 5

2. Because of my problems a number of people are extra nice to me.

1 2 3 4 5 6

3. I will do anything to get rid of my problems.

1 2 3 4 5 6

4. I do not believe that this is the right treatment for me.

1 2 3 4 5 6

5. I urgently need help in solving my problems.

1 2 3 4 5 6

6. I'm certain that I shall also practice at home the things I learn in treatment.

1 2 3 4 5 6

7. I expect to benefit more from therapy if I actively participate in it.

1 2 3 4 5 6

8. Actually, I embarked upon therapy on the insistence of other people.

1 2 3 4 5 6

9. I'm willing to put work or other activities aside in order to attend treatment sessions.

1 2 3 4 5 6

10. My problems make me feel ashamed.

1 2 3 4 5 6

11. I keep my appointment, no matter what.

1 2 3 4 5 6

12. I'm not very optimistic about the outcome of the treatment I'm about to begin.

1 2 3 4 5 6

13. I'm prepared to work on myself for awhile.

1 2 3 4 5 6

14. I think I'm difficult to treat. 1 2 3 4 5 6 15. I can really talk about my

problems with a number of people.

1 2 3 4 5 6

16. I'm willing to postpone other 1 2 3 4 5 6

267

NML-2 Rate the extent to which each statement applies to you on a 6-point scale, ranging from 1, "not at all applicable" to 6, "very applicable".

' ) * * - . . . » . . . , J* .. . . » . # *

1. My problems make me profoundly unhappy.

2. Because of my problems a number of people are extra nice to me.

3. I will do anything to get rid of my problems.

4. I do not believe that this is the right treatment for me.

5. I urgently need help in solving my problems.

6. I'm certain that I shall also practice at home the things I learn in treatment.

7. I expect to benefit more from therapy if I actively participate in it.

8. Actually, I embarked upon therapy on the insistence of other people.

9. I'm willing to put work or other activities aside in order to attend treatment sessions.

10. My problems make me feel ashamed.

11. I keep my appointment, no matter what.

12. I'm not very optimistic about the outcome of the treatment I'm about to begin.

13. I'm prepared to work on myself for awhile.

14. I think I'm difficult to treat. 15. I can really talk about my

problems with a number of people.

16. I'm willing to postpone other

Not at all Very applicable k , apflic#le

1

1

1

1

1

1

1

1

1

1

1

1

1

1 1

1

2

2

2

2

2

2

2

2

2

2

2

2

2

2 2

2

3

3

3

3

3

3

3

3

3

3

3

3

3

3 3

3

4

4

4

4

4

4

4

4

4

4

4

4

4

4 4

4

5

5

5

5

5

5

5

5

5

5

5

5

5

5 5

5

6

6

6

6

6

6

6

6

6

6

6

6

6

6 6

6

267

appointments to attend treatment.

17. The cause of my problems lies primarily in my circumstances.

1 2 3 4 5 6

18. I made the right decision in attending therapy.

1 2 3 4 5 6

19. I can only be helped by the very best therapist.

1 2 3 4 5 6

20. My problems make me a nuisance to others.

1 2 3 4 5 6

21. I do not know whether I'll find sufficient time to carry out homework assignments as well.

1 2 3 4 5 6

22. My problems will disappear of their own accord.

1 2 3 4 5 6

23. Previous treatment did not help me.

1 2 3 4 5 6

24. I've tried everything to get rid of my problems.

1 2 3 4 5 6

25. My problems do not bother me. 1 2 3 4 5 6 26. I can't help having problems. 1 2 3 4 5 6 27. I think it's a nuisance having to

carry out homework assignments as well.

1 2 3 4 5 6

28. I believe that this treatment will help me get rid of my problems.

1 2 3 4 5 6

29. Other people notice that I'm functioning less well.

1 2 3 4 5 6

30. I'm known as someone who perseveres.

1 2 3 4 5 6

31. I don't get much support from those around me.

1 2 3 4 5 6

32. Despite my problems I can function well in daily life.

1 2 3 4 5 6

33. There are more quarrels at home because of my problems.

1 2 3 4 5 6

34. If there was medicine that was effective for my problems as therapy, I would prefer to take that.

1 2 3 4 5 6

268

appointments to attend treatment.

17. The cause of my problems lies primarily in my circumstances.

18. I made the right decision in attending therapy.

19. I can only be helped by the very best therapist.

20. My problems make me a nuisance to others.

21. I do not know whether I' 11 find sufficient time to carry out homework assignments as well.

22. My problems will disappear of their own accord.

23. Previous treatment did not help me.

24. I've tried everything to get rid of my problems.

25. My problems do not bother me. 26. I can't help having problems. 27. I think it's a nuisance having to

carry out homework assignments as well.

28. I believe that this treatment will help me get rid of my problems.

29. Other people notice that I'm functioning less well.

30. I'm known as someone who perseveres.

31. I don't get much support from those around me.

32. Despite my problems I can function well in daily life.

33. There are more quarrels at home because of my problems.

34. If there was medicine that was effective for my problems as therapy, I would prefer to take that.

2

2

2

2

2

2

2

2

2 2 2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3 3 3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4 4 4

4

4

4

4

4

4

4

5

5

5

5

5

5

5

5

5 5 5

5

5

5

5

5

5

5

6

6

6

6

6

6

6

6

6 6 6

6

6

6

6

6

6

6

268

Appendix F

Online Classified Notice

Title: University of Regina seeking Volunteers!

We are looking for individuals aged 18-55 years to participate in an online questionnaire on health-related anxiety. Participation is voluntary and anonymous.

Time: 30 minute Internet based questionnaire

Compensation: All participants will be invited to enter their name in a draw for one of three $20 gift certificates.

This research has been approved by the University of Regina Ethics Board

Please visit the following website: http://www.surveymonkey.com/s/2X5YSMH In order to access the survey, you will need to type in the password: anxiety

Or you may contact Michelle Bourgault-Fagnou: bourmich uregina.ca or call 306-585-5369

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Appendix F

Online Classified Notice

Title: University of Regina seeking Volunteers!

We are looking for individuals aged 18-55 years to participate in an online questionnaire on health-related anxiety. Participation is voluntary and anonymous.

Time: 30 minute Internet based questionnaire

Compensation: All participants will be invited to enter their name in a draw for one of three $20 gift certificates.

This research has been approved by the University of Regina Ethics Board

Please visit the following website: http://www.surveymonkev.eom/s/2X5YSMH In order to access the survey, you will need to type in the password: anxiety

Or you may contact Michelle Bourgault-Fagnou: [email protected] or call 306-585-5369

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http://www.surveymonkev.eom/s/2X5YSMH


Appendix G

Information Sheet and Consent Form for Online Study

Information Page

Information for Potential Participants

Project Title: Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors

We are seeking volunteers aged 18 to 55 years to participate in a study examining health anxiety, which is worry you may experience due to bodily sensations or anxiety about health related information. This study is part of a larger study designed to examine the nature and extent of health anxiety among older adults and the efficacy of a cognitive behavioural treatment of health anxiety among seniors. By comparing older adults' scores to younger adults' scores on certain health anxiety measures, we hope to gain a greater understanding of the unique aspects of health anxiety among the older adult population. The principal investigator, Michelle Bourgault-Fagnou, is a Doctoral student in Clinical Psychology in the Department of Psychology, University of Regina. Her supervisor, Dr. Heather Hadjistavropoulos, is a Professor of Psychology, University of Regina.

Voluntary Participation Your participation in this research is completely voluntary. You have the right to withdraw at any time throughout the research project without any consequences or penalty.

Procedure If you agree to participate, you will complete a series of brief questionnaires online about your levels of health anxiety and related symptoms. As you complete the survey, your responses will be saved and you will be asked to click "Next" at the bottom of each page to move onto the next page of questions. At the conclusion of the survey, you will be asked to click "Done" to exit the survey. After you complete the survey, you may enter your e-mail address in a draw to win one of three $20 gift certificates.

Risks and Benefits There are no known risks associated with this online battery of questionnaires. The only cost to you will be the time required to complete the questionnaire. The

270

Appendix G

Information Sheet and Consent Form for Online Study

Information Page

Information for Potential Participants

Project Title: Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors

We are seeking volunteers aged 18 to 55 years to participate in a study examining health anxiety, which is worry you may experience due to bodily sensations or anxiety about health related information. This study is part of a larger study designed to examine the nature and extent of health anxiety among older adults and the efficacy of a cognitive behavioural treatment of health anxiety among seniors. By comparing older adults' scores to younger adults' scores on certain health anxiety measures, we hope to gain a greater understanding of the unique aspects of health anxiety among the older adult population. The principal investigator, Michelle Bourgault-Fagnou, is a Doctoral student in Clinical Psychology in the Department of Psychology, University of Regina. Her supervisor, Dr. Heather Hadjistavropoulos, is a Professor of Psychology, University of Regina.

Voluntary Participation Your participation in this research is completely voluntary. You have the right to withdraw at any time throughout the research project without any consequences or penalty.

Procedure If you agree to participate, you will complete a series of brief questionnaires online about your levels of health anxiety and related symptoms. As you complete the survey, your responses will be saved and you will be asked to click "Next" at the bottom of each page to move onto the next page of questions. At the conclusion of the survey, you will be asked to click "Done" to exit the survey. After you complete the survey, you may enter your e-mail address in a draw to win one of three $20 gift certificates.

Risks and Benefits There are no known risks associated with this online battery of questionnaires. The only cost to you will be the time required to complete the questionnaire. The

270

results of this study may help us gain more information on the nature and extent of health anxiety in the adult population.

Confidentiality You will not be asked to provide your name in order to complete this survey. Any information gathered from you for this study will be kept confidential by the researchers. All results will be summarized into group data, and no identifying information will be used in published works. If you provide your e-mail address for the gift certificate draw, it will not be linked to the information you provide.

Confidentiality and Internet Surveys There is a very small chance that your privacy may not be guaranteed by participating in this online study. Descriptions of the risks are listed below:

a. In order to protect the integrity of the study and to prevent multiple submissions from the same source this survey will record your computer's internet address. All Internet Service Providers assign an identification number to every computer. This number will be temporarily stored in a file until the research is completed. After completion of the research the principal investigator will delete the entire file. The principal investigator will not have access to this information, and it will not be used to identify individuals.

b. When submitting your survey answers via the Internet, there is small possibility your information will be intercepted by unauthorized third parties using sophisticated tools. It should be noted that this rarely occurs and is a risk that can occur at anytime, not just with online surveys, when using a computer connected to the internet.

c. Any computer connected to the Internet will store information about visited websites on the Internet browser's history list and its disk cache. The responses to this survey are only temporarily stored on your computer until you close down your browser window. In other words, after you complete and submit your survey, your computer will automatically delete this information. You may also delete this information by clearing your history list and disk cache.

d. After completion of your survey, the information will be sent directly to the survey software website. The information will then be sent to a private folder that is only accessible by the primary researcher. All responses will be downloaded daily and kept in a secure location by the researcher until completion of the study. The results will be stored on disks, and the information will not be linked to your Internet address.

271

results of this study may help us gain more information on the nature and extent of health anxiety in the adult population.

Confidentiality You will not be asked to provide your name in order to complete this survey. Any information gathered from you for this study will be kept confidential by the researchers. All results will be summarized into group data, and no identifying information will be used in published works. If you provide your e-mail address for the gift certificate draw, it will not be linked to the information you provide.

Confidentiality and Internet Surveys There is a very small chance that your privacy may not be guaranteed by participating in this online study. Descriptions of the risks are listed below:

a. In order to protect the integrity of the study and to prevent multiple submissions from the same source this survey will record your computer's internet address. All Internet Service Providers assign an identification number to every computer. This number will be temporarily stored in a file until the research is completed. After completion of the research the principal investigator will delete the entire file. The principal investigator will not have access to this information, and it will not be used to identify individuals.

b. When submitting your survey answers via the Internet, there is small possibility your information will be intercepted by unauthorized third parties using sophisticated tools. It should be noted that this rarely occurs and is a risk that can occur at anytime, not just with online surveys, when using a computer connected to the internet.

c. Any computer connected to the Internet will store information about visited websites on the Internet browser's history list and its disk cache. The responses to this survey are only temporarily stored on your computer until you close down your browser window. In other words, after you complete and submit your survey, your computer will automatically delete this information. You may also delete this information by clearing your history list and disk cache.

d. After completion of your survey, the information will be sent directly to the survey software website. The information will then be sent to a private folder that is only accessible by the primary researcher. All responses will be downloaded daily and kept in a secure location by the researcher until completion of the study. The results will be stored on disks, and the information will not be linked to your Internet address.

271

Questions and Contact Information Please feel free to contact any the researchers if you have additional questions about the procedures or purpose of this research. If you have questions about this study, feel free to e-mail the researcher, Michelle Bourgault-Fagnou, at [email protected] or call (306) 585-5369. You may also contact Dr. Heather Hadjistavropoulos, at [email protected] or call (306) 585-5133.

Ethics Approval This study has been approved by the Research Ethics Board at the University of Regina. If you have any questions about your rights as a participant in this study you can contact the Chair of the Research Ethics Board at the University of Regina at (306) 585-4775 or by e-mail: [email protected]. If you are calling long distance, please call collect.

Study Results_ A summary of study results will be posted on the website once all data have been collected-and analyzed. You may also contact the researchers, Michelle Bourgault-Fagnou or Dr. Hadjistavropoulos for the research findings. Please see contact information below.

If you prefer to correspond in writing, please use the addresses listed below:

Michelle Bourgault-Fagnou Department of Psychology University of Regina Regina, SK; S4S 0A2 E-mail: [email protected] Phone: (306) 585-5369

Dr. Heather Hadjistavropoulos Department of Psychology University of Regina Regina, SK, S4S 0A2 E-mail: [email protected] Phone: (306) 585-5133

272

Questions and Contact Information Please feel free to contact any the researchers if you have additional questions about the procedures or purpose of this research. If you have questions about this study, feel free to e-mail the researcher, Michelle Bourgault-Fagnou, at [email protected] or call (306) 585-5369. You may also contact Dr. Heather Hadjistavropoulos, at [email protected] or call (306) 585-5133.

Ethics Approval This study has been approved by the Research Ethics Board at the University of Regina. If you have any questions about your rights as a participant in this study you can contact the Chair of the Research Ethics Board at the University of Regina at (306) 585-4775 or by e-mail: [email protected]. If you are calling long distance, please call collect.

Study Results. A summary of study results will be posted on the website once all data have been collected and analyzed. You may also contact the researchers, Michelle Bourgault-Fagnou or Dr. Hadjistavropoulos for the research findings. Please see contact information below.

If you prefer to correspond in writing, please use the addresses listed below:

Michelle Bourgault-Fagnou Dr. Heather Hadjistavropoulos Department of Psychology Department of Psychology University of Regina University of Regina Regina, SK; S4S 0A2 Regina, SK, S4S 0A2 E-mail: [email protected] E-mail: [email protected] Phone: (306) 585-5369 Phone: (306) 585-5133

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Consent Page

Project Title: Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors:

Are you 18 years of age or older? Yes No

Have you read and understood the information page? Yes No

Do you freely and voluntarily consent to take part in the research? Yes No

Completion of this online questionnaire implies consent to participate in this project.

If you have questions, you may e-mail the researcher, Michelle Bourgault-Fagnou, at [email protected] or 306-585-5369

Or, you may contact her supervisor, Dr. Heather Hadjistavropoulos, at heather.hadjistavropoulosguregina.ca or 306-585-5133

You may also contact the Chair of the Research Ethics Board at the University of Regina at (306) 585-4775 or by e-mail: [email protected]

273

Consent Page

Project Title: Testing the Efficacy of a Cognitive Behavioural Treatment of Health Anxiety Among Seniors:

Are you 18 years of age or older? Yes No

Have you read and understood the information page? Yes No

Do you freely and voluntarily consent to take part in the research? Yes No

Completion of this online questionnaire implies consent to participate in this project.

If you have questions, you may e-mail the researcher, Michelle Bourgault-Fagnou, at [email protected] or 306-585-5369

Or, you may contact her supervisor, Dr. Heather Hadjistavropoulos, at [email protected] or 306-585-5133

You may also contact the Chair of the Research Ethics Board at the University of Regina at (306) 585-4775 or by e-mail: [email protected]

273




HEALTH ANXIETY AMONG OLDER ADULTS

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