Pathological Health Anxiety Research Articles

Dropout From Psychological Interventions for Pathological Health Anxiety: A Three-Level Meta-Analysis of Randomized Controlled Trials.

This study aimed to provide the first comprehensive evidence on the prevalence and predictors of dropout in psychological interventions for pathological health anxiety. A database search in Web of Science, EMBASE, PubMed, Scopus, PsycINFO and the Cochrane Central Register of Controlled Trials identified 28 eligible randomized controlled trials (40 intervention conditions; 1783 participants in the intervention condition), published up to 18 June 2024. Three-level meta-analytic results showed a weighted average dropout rate of 9.67% (95% confidence interval [CI] [6.49%, 14.17%]), with dropout equally likely from treatment and control conditions (odds ratio = 1.07, 95% CI [0.80, 1.44]). Moderator analyses indicated no statistically significant effects of study, participant, treatment or therapist characteristics, except for the country of study. These findings suggest that the average dropout rate is relatively low compared with those reported for other mental health conditions and highlight the importance of considering cultural and societal factors when evaluating treatment adherence. Future research should continue to explore the complex and multifaceted factors influencing dropout to improve the design and implementation of psychological interventions for pathological health anxiety.

Joint factor analysis and approximate equipercentile linking of common trait health anxiety measures: a cross-sectional study of the 14-, 18- and 64-item health anxiety inventory, the illness attitude scale, and the 14-item Whiteley Index

BackgroundResearch on health anxiety has bloomed in recent years, but summaries of the literature are complicated by the use of dissimilar self-report questionnaires. Furthermore, these instruments have rarely been administered in parallel, and especially not in clinical samples. In this study, we aimed to investigate the relationship between five widespread health anxiety measures, and to draft guidelines for the conversion of different sum scores.MethodsClinical trial participants with principal pathological health anxiety (n = 335) and a sample of healthy volunteers (n = 88) completed the 14-item Whiteley Index (WI-14), the Illness Attitude Scale (IAS), and the 14-, 18-, and 64-item Health Anxiety Inventory (the HAI-64, HAI-18, and HAI-14). Cross-sectional data from all participants were pooled (N = 423) and we conducted a joint factor analysis and approximate equipercentile linking of the WI-14, IAS, HAI-64, HAI-18, and HAI-14.ResultsInter-scale correlations were high (rs ≥ 0.90 and ≥ 0.88 in adjusted analyses), and the scree plot of the joint factor analysis spoke for a unifactorial solution where 89/105 items (85%) had loadings ≥ 0.40. Most items at the core of this broad trait health anxiety factor pertained to the worry about health, the fear of having or developing a serious disease, and to some extent bodily preoccupation. We present a cross-walk table of observed equipercentile linked sum scores.ConclusionsThis study speaks clearly in favor of the WI-14, IAS, HAI-64, HAI-18, and HAI-14 all tapping into the same trait health anxiety construct, the core of which appears to concern the worry about health, the fear of having or developing a serious disease, and to some extent bodily preoccupation. Based on recently reported cut-offs for the HAI-14, a reasonable cutoff for pathological health anxiety in a psychiatric setting probably lies around 7–8 on the WI-14, 52–53 on the IAS, 82–83 on the HAI-64, and 26–27 on the HAI-18.Trial registrationClinicalTrials.gov NCT01966705, NCT02314065.

What does the clinician have to gain from distinguishing between DSM-5 somatic symptom disorder and illness anxiety disorder in pathological health anxiety?

What does the clinician have to gain from distinguishing between DSM-5 somatic symptom disorder and illness anxiety disorder in pathological health anxiety?

Validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder and illness anxiety disorder in pathological health anxiety: Should we close the chapter?

ObjectiveTo investigate the validity and clinical utility of distinguishing between DSM-5 somatic symptom disorder (SSD) and illness anxiety disorder (IAD) in pathological health anxiety: the excessive and recurrent fear of, or preoccupation with, having or developing a serious health condition. MethodsWe compared SSD to IAD in pathological health anxiety (N = 334) with regard to concurrent, antecedent, and predictive validators. This was primarily a cross-sectional study, though we studied the effect of CBT longitudinally. Because we were interested in the discriminatory value of SSD and IAD over and above trait health anxiety, we used trait health anxiety as a covariate. ResultsSSD (68%; 228/334) vs. IAD (32%; 106/334) differences were mostly non-significant and small in sociodemographics, core clinical characteristics, apparent course, etiological attribution, and physician visits (gs = −0.18–0.20; RRs = 0.84–1.09; IRRs = 0.87–0.99). However, SSD was associated with a significantly higher somatic symptom burden (gs = 0.20–0.72), more psychologist visits (IRR = 2.02, 95% CI: 1.24–3.28), and slightly higher disability (g = 0.22, 95% CI: 0.03–0.42). There was no significant difference in symptom reduction during CBT (g = −0.16, 95% CI: −0.37-0.05). ConclusionAlthough not all differences between SSD and IAD in pathological health anxiety seem to be explained by the level of trait health anxiety, the SSD vs. IAD distinction appears to convey little useful information in pathological health anxiety. Tentatively, considering the well-documented clinical characteristics and effective clinical interventions, it is probably most helpful to regard pathological health anxiety as a de facto anxiety or perhaps obsessive-compulsive spectrum disorder, regardless of the DSM-5 diagnosis of SSD or IAD.

Inhibitory Learning-Based Exposure Therapy for Patients With Pathological Health Anxiety: Results From a Single Case Series Study

Exposure to illness-related stimuli is a crucial component of CBT for pathological health anxiety. Modern exposure approaches focus on forming inhibitory associations and provide promising results. An implementation in the treatment of pathological health anxiety is still missing. The present single case series study investigated the applicability and effects of an inhibitory learning-based exposure approach (12 sessions) on health anxiety, safety behavior, and tolerance for aversive states in n = 7 outpatients (age: M = 35.14, SD = 8.43) with a DSM-5 Illness Anxiety Disorder or Somatic Symptom Disorder with predominant health worries in multilevel models. A high intervention satisfaction and little adverse effects were reported. A significant(ly) (steepened) reduction of health anxiety (b = −0.10, pbaseline < .001, ppre-intervention = .003), and body checking behavior (b = −0.14, pbaseline/pre-intervention < .001), and a significant increase in distress tolerance (b = 0.07, pbaseline = .02, ppre-intervention = .004), discomfort tolerance (b = 0.11, pbaseline/pre-intervention < .001), and insecurity tolerance (b = 0.13, pbaseline/pre-intervention < .001) were observed during the intervention in comparison to the baseline and pre-intervention phase. The present study provided first evidence that the principles of inhibitory learning can be effectively applied to the exposure-based treatment of pathological health anxiety.

Do patients with pathological health anxiety fear COVID-19? A time-course analysis of 12 single cases during the “first wave” of the COVID-19 pandemic in Germany

ObjectivePre-existing health anxiety is associated with an intensified affective response to the novel COVID-19 pandemic in the general population. Still, results on the reaction of people with a diagnosis of pathological health anxiety (i.e., hypochondriasis) are scarce. MethodsIn the present study, we investigated the course of (health) anxiety related to SARS-CoV-2/COVID-19 in comparison to (health) anxiety related to other severe diseases (e.g., cancer) in a sample of 12 patients with the diagnosis of pathological health anxiety during the “first wave” of the COVID-19 pandemic in Germany. Both SARS-CoV-2 related anxiety and anxiety related to other severe diseases were assessed weekly over 16 measurement points (30.03.-19.07.2020) and primarily analyzed with fixed effects regression analyses. ResultsUnexpectedly, SARS-CoV-2 related anxiety was on average significantly lower than anxiety related to other severe diseases (d = −0.54, p < .001) and not significantly associated with anxiety related to other severe diseases or pre-COVID-19 health anxiety. ConclusionIt therefore appears premature to assume that SARS-CoV-2 related anxiety and other health worries are necessarily strongly interrelated and comparably high in people with pathological health anxiety.

Initial assessment of patients with putative functional disorders in medical settings

Patients presenting with symptoms suggestive of functional disorder are very frequent in practice. While it is always necessary to exclude treatable organic pathology, there are important clues in the presentation that can help the clinician. In particular, it is important to identify pathological health anxiety early in assessment, as failure to do so may lead to unnecessary investigations and the dangerous path of reinforcing reassurance. Because full assessment of functional symptoms takes time, it is suggested that a clinical support nurse with some training in psychological management should be available to guide the management of the patients with these disorders. Such support nurses, based in the clinic, offer a seamless way of providing care that is not achieved by external referral to psychologists or equivalent staff.

Influence of apparently negative personality characteristics on the long-term outcome of health anxiety: Secondary analysis of a randomized controlled trial.

It is known that personality has an influence on the outcome of mental state disorders, but detailed studies on its long-term impact are few. We examined the influence of personality status on the 8-year outcome of health anxiety and its relationship to the effects of cognitive behaviour therapy in a randomized controlled trial. This study aims to examine both the usefulness of the diagnosis of personality disorder and an additional measure of pathological dependence, in predicting the outcome of medical patients with health anxiety treated with cognitive behaviour therapy. Because the influence of personality is often shown in the long term, these assessments covered the period of 8years after randomization. An additional aim is to examine the costs of different levels of personality dysfunction in each treatment group. Personality dysfunction, using both ICD-10 and ICD-11 classifications of severity, was assessed at baseline by interview in a randomized controlled trial. Patients were also assessed for pathological dependence using the Dependent Personality Questionnaire, also scored along a severity dimension. Four hundred forty-four patients from medical clinics with pathological health anxiety were treated with a modified form of cognitive behaviour therapy for health anxiety (CBT-HA) or standard care. Total costs over follow-up were calculated from hospital data and compared by personality group. At baseline, 381 (86%) had some personality dysfunction, mainly at the lower level of personality difficulty (not formally a disorder). One hundred eighty four (41%) had a personality disorder. A similar proportion was found with regard to dependent personality. Using the ICD-10 classification, 153 patients (34.6%) had a personality disorder, with 83 (54.2%) having anxious or dependent personality disorder, 20 (13.1%) having an anankastic disorder, but also with 66 (43.1%) having mixed disorder. During initial treatment, those with personality disorder adhered more closely to CBT-HA, and after 8years, they had a significantly better outcome than those with personality difficulty and no personality disorder (p<0.002). Similar results were found in those scoring high on the Dependent Personality Questionnaire. All these differences increased over the follow-up period. Costs were similar in all groups but were somewhat higher in the CBT-HA one; this finding is hypothesised to be due to fuller hospital treatment once health anxiety is discounted. Personality disorder in people with health anxiety, particularly in those who have anxious and dependent traits, reinforces the benefits of cognitive behaviour therapy, particularly in the longer term. © 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.

COVID-19 health anxiety.

COVID-19 health anxiety.

Somatic Symptom Perception and Interoception

Abstract. Models of chronic somatic symptoms assume that abnormalities in interoception are related to the development and maintenance of symptom distress. Different models, however, disagree on the exact nature of the assumed abnormality: cognitive-behavioral models stress a hypervigilant cognitive style (predicting higher interoceptive accuracy) whereas predictive processing models assume a less detailed sensory processing (predicting lower interoceptive accuracy). This study aimed at testing the relationship between interoception and symptom perception. Using structural equation modeling, associations between cardiac interoception and symptom perception were tested in a sample of students ( n = 316) and a second heterogeneous sample ( n = 340, including 63 patients with either pathological health anxiety or a somatoform disorder according to DSM-IV). Stronger sensory symptom perceptions in the cardiorespiratory system were associated with lower interoceptive accuracy in sample 2. The findings are more in line with the predictive processing approach, suggesting less detailed and more biased interoception being associated with chronic somatic symptom distress.

Sustained benefit of cognitive behaviour therapy for health anxiety in medical patients (CHAMP) over 8 years: a randomised-controlled trial.

Health anxiety is an under-recognised but a frequent cause of distress. It is particularly common in general hospitals. We carried out an 8-year follow-up of medical out-patients with health anxiety (hypochondriasis) enrolled in a randomised-controlled trial in five general hospitals in London, Middlesex and Nottinghamshire. Randomisation was to a mean of six sessions of cognitive behaviour therapy adapted for health anxiety (CBT-HA) or to standard care in the clinics. The primary outcome was a change in score on the Short Health Anxiety Inventory, with generalised anxiety and depression as secondary outcomes. Of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics, 306 (68.9%) were followed-up 8 years after randomisation, including 36 who had died. The study is registered with controlled-trials.com, ISRCTN14565822. There was a significant difference in the HAI score in favour of CBT-HA over standard care after 8 years [1.83, 95% confidence interval (CI) 0.25-3.40, p = 0.023], between group differences in generalised anxiety were less (0.54, 95% CI -0.29 to 1.36), p = 0.20, ns), but those for depression were greater at 8 years (1.22, 95% CI 0.42-2.01, p < 0.003) in CBT-HA than in standard care, most in standard care satisfying the criteria for clinical depression. Those seen by nurse therapists and in cardiology and gastrointestinal clinics achieved the greatest gains with CBT-HA, with greater improvement in both symptoms and social function. CBT-HA is a highly long-term effective treatment for pathological health anxiety with long-term benefits. Standard care for health anxiety in medical clinics promotes depression. Nurse therapists are effective practitioners.

Optimizing Exposure Therapy for Pathological Health Anxiety: Considerations From the Inhibitory Learning Approach

Exposure therapy has demonstrated its efficacy in the treatment of pathological health anxiety—however, psychotherapy research reveals that many patients do not show a clinically significant change. Therefore, improvements are necessary to optimize psychotherapy for pathological health anxiety. Most treatment rationales refer to habituation during exposure as the central mechanism of change. However, there is evidence that extinction learning is mediated by inhibitory learning processes. Targeting these processes may help to improve treatment outcomes in pathological health anxiety. The aim of this review was to adapt, from the inhibitory learning approach and empirical findings, the most promising strategies for the exposure-based treatment of pathological health anxiety. The exposure-optimizing strategies adapted are expectancy violation, combination, variability in contexts and stimuli, affect labeling, and removal of safety signals. A case example illustrates how to implement these methods for patients with pathological health anxiety.

Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years.

Health anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care. To determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive-behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medical outpatients. Randomised controlled trial. Five general hospitals in London, Middlesex and Nottinghamshire. A total of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics who scored ≥ 20 points on the Health Anxiety Inventory (HAI) and satisfied diagnostic requirements for hypochondriasis. Those with current psychiatric disorders were excluded, but those with concurrent medical illnesses were not. Cognitive-behaviour therapy for health anxiety - between 4 and 10 1-hour sessions of CBT-HA from a health professional or psychologist trained in the treatment. Standard care was normal practice in primary and secondary care. Primary - researchers masked to allocation assessed patients at baseline, 3, 6, 12, 24 months and 5 years. The primary outcome was change in the HAI score between baseline and 12 months. Main secondary outcomes - costs of care in the two groups after 24 and 60 months, change in health anxiety (HAI), generalised anxiety and depression [Hospital Anxiety and Depression Scale (HADS)] scores, social functioning using the Social Functioning Questionnaire and quality of life using the EuroQol-5 Dimensions (EQ-5D), at 6, 12, 24 and 60 months, and deaths over 5 years. Of the 28,991 patients screened over 21 months, 5769 had HAI scores of ≥ 20 points. Improvement in HAI scores at 3 months was significantly greater in the CBT-HA group (mean number of sessions = 6) than in the standard care, and this was maintained over the 5-year period (overall p < 0.0001), with no loss of efficacy between 2 and 5 years. Differences in the generalised anxiety (p = 0.0018) and depression scores (p = 0.0065) on the HADS were similar in both groups over the 5-year period. Gastroenterology and cardiology patients showed the greatest CBT gains. The outcomes for nurses were superior to those of other therapists. Deaths (n = 24) were similar in both groups; those in standard care died earlier than those in CBT-HA. Patients with mild personality disturbance and higher dependence levels had the best outcome with CBT-HA. Total costs were similar in both groups over the 5-year period (£12,590.58 for CBT-HA; £13,334.94 for standard care). CBT-HA was not cost-effective in terms of quality-adjusted life-years, as measured using the EQ-5D, but was cost-effective in terms of HAI outcomes, and offset the cost of treatment. Many eligible patients were not randomised and the population treated may not be representative. CBT-HA is a highly effective treatment for pathological health anxiety with lasting benefit over 5 years. It also improves generalised anxiety and depressive symptoms more than standard care. The presence of personality abnormality is not a bar to successful outcome. CBT-HA may also be cost-effective, but the high costs of concurrent medical illnesses obscure potential savings. This treatment deserves further research in medical settings. Current Controlled Trials ISRCTN14565822. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 50. See the NIHR Journals Library website for further project information.

Scary symptoms? Functional magnetic resonance imaging evidence for symptom interpretation bias in pathological health anxiety.

Patients with pathological health anxiety (PHA) tend to automatically interpret bodily sensations as sign of a severe illness. To elucidate the neural correlates of this cognitive bias, we applied an functional magnetic resonance imaging adaption of a body-symptom implicit association test with symptom words in patients with PHA (n=32) in comparison to patients with depression (n=29) and healthy participants (n=35). On the behavioral level, patients with PHA did not significantly differ from the control groups. However, on the neural-level patients with PHA in comparison to the control groups showed hyperactivation independent of condition in bilateral amygdala, right parietal lobe, and left nucleus accumbens. Moreover, patients with PHA, again in comparison to the control groups, showed hyperactivation in bilateral posterior parietal cortex and left dorsolateral prefrontal cortex during incongruent (i.e., harmless) versus congruent (i.e., dangerous) categorizations of body symptoms. Thus, body-symptom cues seem to trigger hyperactivity in salience and emotion processing brain regions in PHA. In addition, hyperactivity in brain regions involved in cognitive control and conflict resolution during incongruent categorization emphasizes enhanced neural effort to cope with negative implicit associations to body-symptom-related information in PHA. These results suggest increased neural responding in key structures for the processing of both emotional and cognitive aspects of body-symptom information in PHA, reflecting potential neural correlates of a negative somatic symptom interpretation bias.

Neural correlates of an attentional bias to health-threatening stimuli in individuals with pathological health anxiety.

An attentional bias to health-threat stimuli is assumed to represent the primary pathogenetic factor for the development and maintenance of pathological health anxiety (PHA; formerly termed "hypochondriasis"). However, little is known about the neural basis of this attentional bias in individuals with PHA. A group of patients with PHA, a group of depressed patients and a healthy control group completed an emotional Stroop task with health-threat (body symptom and illness) words and neutral control words while undergoing functional MRI. We included 33 patients with PHA, 28 depressed patients and 31 controls in our analyses. As reflected in reaction times, patients with PHA showed a significantly stronger attentional bias to health-threat words than both control groups. In addition, patients with PHA showed increased amygdala and rostral anterior cingulate cortex activation for body symptom, but not for illness words. Moreover, only in patients with PHA amygdala activation in response to symptom words was positively associated with higher arousal and more negative valence ratings of the body symptom word material. A control group of patients with an anxiety disorder but without PHA would have helped to define the specificity of the results for PHA. The attentional bias observed in patients with PHA is associated with hyperactivation in response to body symptom words in brain regions that are crucial for an arousal-related fear response (e.g., the amygdala) and for resolving emotional interference (e.g., the rostral anterior cingulate cortex). The findings have important implications for the nosological classification of PHA and suggest the application of innovative exposure-based interventions for the treatment of PHA.

Interoception in pathological health anxiety.

According to cognitive-behavioral models, pathological health anxiety is triggered and maintained by the perception of mostly mild and benign bodily sensations that are misinterpreted as signs of illness. Arguably, abnormalities in interoception may account for this misguided preoccupation with somatic sensations. Using a multimethod approach, the current study investigated possible abnormalities in interoception in patients with pathological health anxiety (PHA; n = 51) and healthy participants (n = 56). Different types of interoception were assessed with a heartbeat-tracking task and a signal-detection task for nonspecific skin conductance fluctuations (NSCFs task). Patients compared with healthy participants showed a more liberal interoceptive response bias for NSCFs, t(79) = 2.32, p = .02, d = 0.53, 95% confidence interval (CI) (0.30, 0.68). Specifically, patients with a comorbid anxiety disorder compared with healthy participants exhibited a significantly higher interoceptive sensitivity for NSCFs, t(57) = 3.12, p < .01, d = 0.89, 95% CI (0.54, 1.12). No evidence for higher interoceptive sensitivity in PHA (neither in the heartbeat mental tracking task nor in the NSCF task) was observed after accounting for comorbid anxiety disorders. The findings suggest that higher interoceptive sensitivity might not be specific to health anxiety, but rather associated with factors shared with the anxiety disorders. Biased (i.e., more liberal) interoceptive processing appears more specific to health anxiety, but further studies using larger sample sizes and a multimethod approach for the assessment of interoception are needed to more completely unravel the role of interoception in health anxiety. (PsycINFO Database Record

Dimensions of dependence and their influence on the outcome of cognitive behaviour therapy for health anxiety: randomized controlled trial.

The personality trait of dependence is common in health-seeking behaviour. We therefore examined its impact in a large randomized controlled trial of psychological treatment for health anxiety. To test whether dependent personality traits were positive or negative in determining the outcome of an adapted form of cognitive behaviour therapy for health anxiety (CBT-HA) over the course of 5 years and whether dependent personality dysfunction could be viewed dimensionally in a similar way to the new ICD-11 diagnostic system for general personality disorder. Dependent personality dysfunction was assessed using a self-rated questionnaire, the Dependent Personality Questionnaire, at baseline in a randomized controlled trial of 444 patients from medical clinics with pathological health anxiety treated with a modified form of CBT-HA or standard treatment in the medical clinics, with assessment on five occasions over 5 years. Dependent personality dysfunction was assessed using four severity groups. Patients with mild and moderate dependent personality disorder treated with CBT-HA showed the greatest reduction in health anxiety compared with standard care, and those with no dependent dysfunction showed the least benefit. Patients with higher dependent traits received significantly more treatment sessions (8.6) than those with low trait levels (5.4) (p < 0.01). The results suggest that patients treated with cognitive behaviour therapy for health anxiety respond better if they have moderate dependent personality. The reasons for this may be related to better adherence to psychological treatment and greater negative effects of frequent reassurance and excessive consultation in those treated in standard care. Copyright © 2016 John Wiley & Sons, Ltd.

Cough Is Dangerous: Neural Correlates of Implicit Body Symptoms Associations.

The negative interpretation of body sensations (e.g., as sign of a severe illness) is a crucial cognitive process in pathological health anxiety (HA). However, little is known about the nature and the degree of automaticity of this interpretation bias. We applied an implicit association test (IAT) in 20 subjects during functional magnetic resonance imaging (fMRI) to investigate behavioral and neural correlates of implicit attitudes toward symptom words. On the behavioral level, body symptom words elicited strong negative implicit association effects, as indexed by slowed reaction times, when symptom words were paired with the attribute “harmless” (incongruent condition). fMRI revealed increased activation in the dorsolateral prefrontal cortex (DLPFC) and posterior parietal cortex for the comparison of incongruent words with control words, as well as with a lower significance threshold also in comparison to congruent words. Moreover, activation in the DLPFC, posterior parietal cortex, nucleus accumbens, and cerebellum varied with individual levels of HA (again, in comparison to control words, as well as with a lower significance threshold also in comparison to congruent words). Slowed reaction times as well as increased activation in dorsolateral prefrontal and posterior parietal cortex point to increased inhibitory demands during the incongruent IAT condition. The positive association between HA severity and neural activity in nucleus accumbens, dorsolateral prefrontal, and posterior parietal cortex suggests that HA is characterized by both intensified negative implicit attitudes and hampered cognitive control mechanisms when confronted with body symptoms.

Supplemental Material for Interoception in Pathological Health Anxiety

Supplemental Material for Interoception in Pathological Health Anxiety

Cognitive Biases in Pathological Health Anxiety

Pathological health anxiety refers to the medically unfounded fear of suffering from a severe illness. Differences in cognitive processes related to attention, memory, and evaluation of health threat have been hypothesized to underlie pathological health anxiety. In no study, however, have researchers systematically and simultaneously assessed different cognitive biases. On the basis of the idea that multiple cognitive biases simultaneously contribute to psychopathology (the combined-cognitive-bias hypothesis), we compared 88 patients with pathological health anxiety, 52 patients with depressive disorder, and 52 healthy participants on their performance in several cognitive tasks involving health-threatening content. Individuals with pathological health anxiety showed a stronger attentional bias to health-threat-related information, more negative explicit (but not implicit) evaluations of health threat, and biased response behavior in light of health threat. The results suggest that stronger bindings between feelings of arousal and health-threatening information in working memory might be crucial for the higher salience of health-threatening contents in pathological health anxiety.