Mechanistic studies in pathological health anxiety: A systematic review and emerging conceptual framework

• Published in: Journal of affective disorders 2024-08, Vol.358, p.222-249
• Main Authors: Guthrie, Andrew J., Paredes-Echeverri, Sara, Bleier, Cristina, Adams, Caitlin, Millstein, Daniel J., Ranford, Jessica, Perez, David L.
• Format: Article
• Language: English
• Subjects: Anxiety Disorders - physiopathology; Anxiety Disorders - psychology; Cyberchondria; Health anxiety; Humans; Hypochondriasis; Hypochondriasis - psychology; Illness anxiety disorder; Pathological health anxiety
• ISSN: 0165-0327; 1573-2517; 1573-2517
• DOI: 10.1016/j.jad.2024.05.029

Pathological health anxiety (PHA) (e.g., hypochondriasis and illness anxiety disorder) is common in medical settings and associated with increased healthcare costs. However, the psychological and neurobiological mechanisms contributing to the development and maintenance of PHA are incompletely understood. We performed a systematic review to characterize the mechanistic understanding of PHA. PubMed, PsycINFO, and Embase databases were searched to find articles published between 1/1/1990 and 12/31/2022 employing a behavioral task and/or physiological measures in individuals with hypochondriasis, illness anxiety disorder, and PHA more broadly. Out of 9141 records identified, fifty-seven met inclusion criteria. Article quality varied substantially across studies, and was overall inadequate. Cognitive, behavioral, and affective findings implicated in PHA included health-related attentional and memory recall biases, a narrow health concept, threat confirming thought patterns, use of safety-seeking behaviors, and biased explicit and implicit affective processing of health-related information among other observations. There is initial evidence supporting a potential overestimation of interoceptive stimuli in those with PHA. Neuroendocrine, electrophysiology, and brain imaging research in PHA are particularly in their early stages. Included articles evaluated PHA categorically, suggesting that sub-threshold and dimensional health anxiety considerations are not contextualized. Within an integrated cognitive-behavioral-affective and predictive processing formulation, we theorize that sub-optimal illness and health concepts, altered interoceptive modeling, biased illness-based predictions and attention, and aberrant prediction error learning are mechanisms relevant to PHA requiring more research. Comprehensively investigating the pathophysiology of PHA offers the potential to identify adjunctive diagnostic biomarkers and catalyze new biologically-informed treatments. •Systematic review of mechanistic studies in pathological health anxiety.•Cognitive, behavioral and affective constructs are implicated.•Neurobiological research in pathological health anxiety remains limited.•A predictive processing framework for pathological health anxiety is offered.