- Email: [email protected]
Does anxiety about health influence eating patterns and shape-related body checking among females?
Personality and Individual Differences 43 (2007) 319–328 www.elsevier.com/locate/paid
Does anxiety about health influence eating patterns and shape-related body checking among females? Heather Hadjistavropoulos *, Brandy Lawrence Heather Hadjistavropoulos, Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, Canada SK S4S 0A2 Received 13 April 2006; received in revised form 7 November 2006; accepted 29 November 2006 Available online 26 January 2007
Abstract In clinical practice, patients who have elevated worries about health often report a desire to diet and a preoccupation with body shape; furthermore, they report that information about dieting can trigger significant health anxiety. To date, there has been no research that has systematically investigated the relationships among elevated health anxiety, eating patterns, and body shape preoccupation. In this study, 122 female participants completed measures of health anxiety, eating patterns, and body checking. Participants were also randomly given either positive (n = 59) or negative (n = 63) information about the effects of dieting on health allowing us to examine the consequences of receiving differential dieting information on health anxious and non-health anxious individuals. Health anxiety was positively correlated with dieting and food preoccupation; it was also correlated with body checking to assess shape. Analysis of variance showed that after reading both positive and negative information about dieting, individuals highly health anxious experienced greater concern about their health and a greater desire to diet and exercise than individuals with lower levels of health anxiety. Further research should explore dieting and body shape checking as behavioural responses to health anxiety, and, clinically, practitioners should consider monitoring these behaviours when assessing and treating health anxiety. 2006 Elsevier Ltd. All rights reserved. Keywords: Health anxiety; Dieting; Food preoccupation; Body checking
*
Corresponding author. Tel.: +1 306 585 5133; fax: +1 306 585 5429. E-mail address: [email protected] (H. Hadjistavropoulos).
0191-8869/$ - see front matter 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2006.11.021
320
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
0. Introduction Anecdotally, those who are worried about their health frequently report that anxiety about health can initiate a change in eating patterns, such as dieting or preoccupation with food. Health anxiety is defined as health-related fears and beliefs that one’s physical well-being is threatened (Asmundson, Taylor, & Cox, 2001). Health anxiety ranges on a continuum from mild to severe, is normally distributed in the population and in its extreme form is apparent in those with mental health disorders such as hypochondriasis and panic disorder (Taylor & Asmundson, 2004). Health anxiety is clinically important even when patients do not meet diagnostic criteria for a mental disorder, and can have a significant impact on emotional well-being and health behaviour (Hadjistavropoulos, Craig, & Hadjistavropoulos, 1998). In primary care outpatients, severe health anxiety occurs in 2–7% of the population (American Psychiatric Association, 2000) and, in the community, prevalence rates for severe health anxiety range from 1.5% to 4.5% (Asmundson et al., 2001). The cognitive-behavioural model of health anxiety (Salkovskis & Warwick, 1986) postulates that cognitions (e.g., the belief that physical symptoms always indicate a serious illness), formulated based on past experiences, are central in the development of health anxiety. Health anxiety is then spawned by a combination of dysfunctional health beliefs and critical incidents (e.g., physical symptoms, information on health). Information about dieting could potentially trigger health anxiety although this has not been investigated. Once present, health anxiety results in catastrophic thoughts about health, negative emotion, and an attentional focus on health-related information (Salkovskis & Warwick, 1986). Individuals also demonstrate protective behaviours designed to reduce health anxiety, such as avoiding illness-related information or seeking medical reassurance (Taylor & Asmundson, 2004). Dieting and body checking could be further behaviours designed to reduce health anxiety, although again this has not been investigated. Body checking involves examining one’s overall appearance or inspecting specific body parts. It has been hypothesized that checking behaviours resemble compulsions and may initially serve to reassure the individual that no problem exists; body checking, however, in the longer term paradoxically may serve to increase rather than decrease anxiety (Reas, Whisenhunt, Netemeyer, & Williamson, 2002). Recently there has been an upsurge of research conducted on health anxiety (Asmundson et al., 2001), but to date the relationship between health anxiety and eating patterns and shape-related body checking has not been explored. However, a review of literature on anxiety in general suggests that a dual causal pathway may exist between anxiety and eating patterns and shape-related body checking. Research shows, for instance, that trait anxiety is associated with dieting, food preoccupation and restrained eating in non-clinical samples (Miller, Scmidt, Vaillancourt, McDougall, & Laliberte, 2006); negative affect is also associated with increased body checking (Reas, White, & Grilo, 2006). Dieting and body checking also appear to trigger variations in state anxiety (e.g., Appleton & McGowan, 2006; Reas, Grilo, Masheb, & Wilson, 2005). In the clinical realm, research on co-morbidity in eating disorders indicates that a high proportion of individuals with anorexia and bulimia nervosa suffer from some type of anxiety disorder (Bulik, Sullivan, Carter, & Joyce, 1996). The purpose of this study was to expand on this previous body of research and explore the relationship between anxiety specifically focused on health, and eating patterns and body checking. To further understand the relationship between health anxiety and dieting, this study sought to explore whether positive versus negative information about dieting had a different impact on indi-
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
321
viduals who were health anxious versus non-health anxious. It is common to find contradictory information on dieting in the media. On the one hand, dieting is described as reducing morbidity and mortality. On the other hand, however, increasingly there are reports that diets are harmful, with weight cycling in particular being associated in some studies with progressive difficulties losing weight, an increased preference for dietary fat, cardiovascular disease, binge eating and depression (Brownell & Rodin, 1994). The cognitive-behavioural theory of health anxiety (Salkovskis & Warwick, 1986) and research findings (Haenen, de Jong, Schmidt, Stevens, & Visser, 2000) on health anxiety in general led us to predict that health anxiety would have moderate to strong positive relationships with body checking and dieting behaviours. Furthermore, we predicted that health anxious individuals would interpret all information about dieting, regardless of whether it was positive or negative in nature, as threatening. In this way, health anxious individuals were expected to report greater anxiety in response to this information compared to non-health anxious individuals. Individuals who were non-health anxious, on the other hand, were expected to respond with anxiety to information on the negative effects of dieting, but not the positive effects of dieting; thus, their level of anxiety would be more consistent with the information they received.
1. Method 1.1. Sample A total of 122 females participated in this study with an average age of 19.63 years (SD = 2.65). The average reported BMI was 21.98 (SD = 3.76). Participants were divided into high or low levels of health anxious groups by performing a median split on the Illness Attitudes Scale (Kellner, Abbott, Winslow, & Pathak, 1987) total score (scores of 37 or lower were coded as low and scores of 38 or higher were coded as high). Previous research shows that deriving groups of health anxious and non-health anxious participants in this way results in meaningful differences between groups (Hadjistavropoulos, Hadjistavropoulos, & Quine, 2000). Students were randomly assigned to receive either positive (n = 59) or negative information (n = 63) about dieting, thus creating a 2 (low versus high health anxiety) · 2 (positive versus negative information about dieting) design. Based on a power analysis, we determined that approximately 30 participants were needed in each group. With random assignment and median split, there were 29 individuals in the low health anxious positive dieting information group, 29 individuals in the low health anxious negative dieting information group, 30 individuals in the high health anxious positive dieting information group and 34 individuals in the high health anxious negative dieting information group. 1.2. Procedure The study was posted on the Psychology Participant Bulletin Board at the University of Regina, Saskatchewan and students signed up to complete the study during various time slots. Participants were administered the Illness Attitudes Scale (Kellner et al., 1987), Eating Attitudes Test-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982), and Body Checking Questionnaire (Reas et al., 2002). Students were then randomly assigned to receive either positive or negative information about dieting.
322
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
Participants read through a brochure and then responded to a questionnaire about the brochure. They were told the brochure was created to educate first year students about dieting. Due to concerns about response bias, participants were not informed that we were studying their level of anxiety in response to varying information about dieting. In the positive dieting condition, participants were administered a brochure that described the positive consequences of dieting, including reduced cholesterol levels, risk of diabetes, and cardiovascular disease (Brownell & Rodin, 1994). In the negative dieting condition, the brochure emphasized the negative consequences of dieting that also have been presented in the literature. In particular, in the negative dieting condition we highlighted how dieting has been associated with an increased risk of being overweight and that dieting, resulting in weight fluctuations, has been associated with increased risk of developing cardiovascular disease and hypertension (Brownell & Rodin, 1994). Both brochures were matched for word and picture content, to ensure that the only difference between the two was the negative versus positive information presented. After reading the brochure, participants were administered a questionnaire developed for this study asking about responses to the dieting brochure. Participants were then thoroughly debriefed as to the true nature of the study using a debriefing script. Participants were given the name of a psychologist to contact if they felt they needed to talk to someone about the study. Ethical approval for the study was acquired from the Institutional Review Board. 1.3. Measures 1.3.1. Demographic questions The following background questions were asked of participants: age, height, and weight. From this information, each participant’s body mass index (BMI) was calculated (weight in kilograms divided by height in meters squared). 1.3.2. Illness attitudes scale (IAS) The IAS is a 27 item instrument with items rated on a 0–4 scale (Kellner et al., 1987). The scale was devised to assess fears, beliefs, and attitudes associated with hypochondriasis and abnormal illness behaviours. Nine subscales (3 items each) were initially identified, but factor analysis with students suggests that a hierarchical model is more appropriate, with four lower order factors loading on a single higher order factor. The four factors measure: (1) fear of illness and pain, (2) effects of symptoms on functioning, (3) treatment seeking behaviour, and (4) disease conviction (e.g., certainty that one has a disease); (Hadjistavropoulos, Frombach, & Asmundson, 1999). The IAS has good test–retest reliability, convergent validity with other measures of health anxiety, and known groups validity (Stewart & Watt, 2001). In a sample of 156 females and 41 male undergraduates, Stewart and Watt (2000) found that the IAS correlates in predictable ways with other measures of anxiety. Scores can range from 0 to 108 with patients who have a DSM-IV diagnosis of hypochondriasis typically obtaining scores above 50 (Bouman & Visser, 1998). 1.3.3. Eating Attitudes Test-26 (EAT-26) The EAT-26 is a 26-item questionnaire that is designed to reflect a range of behaviours including dieting (e.g., eating diet foods, being aware of calorie content of foods), food preoccupation (e.g., preoccupied with food, impulse to vomit after meals), and oral control (e.g., avoid eating
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
323
when hungry, feeling that others would prefer the individual to eat more) (Garner et al., 1982). The participant is required to judge whether each item applies to them ‘‘always,’’ ‘‘very often,’’ ‘‘often,’’ ‘‘somewhat,’’ ‘‘rarely,’’ and ‘‘never.’’ Extreme responses (‘‘always’’) are rated as a 3 and less extreme responses (‘‘very often’’ and ‘‘often’’) are rated as 2 or 1; the lowest three ratings (‘‘somewhat,’’ ‘‘rarely,’’ and ‘‘never’’) are given a score of 0. Possible scores on the EAT-26 range from 0 to 78 with females with eating disorders often obtaining scores above 36 (Garner et al., 1982). The EAT-26 is a reliable (e.g., internal consistency, test–retest reliability) and valid measure (correlates with other measures, identifies individuals with disordered eating) of dysfunctional eating attitudes (Mintz & O’Halloran, 2000) among female university students. 1.3.4. Body checking questionnaire (BCQ) The BCQ is a recently developed 23-item measure of the body checking behaviours associated with body shape concerns (Reas et al., 2002). The items are scored on a 5-point Likert scale, with responses ranging from 1 (never) to 5 (very often). The BCQ is composed of three subscales measuring checking of overall appearance (e.g., check my reflection in a mirror), checking of specific body parts (e.g., pinch my stomach, upper arms), and idiosyncratic checking rituals (e.g., check to see how ring fits) and has been found to be reliable (e.g., internally consistent, adequate test–rest reliability) and valid (e.g., correlated with related measures, differentiates between known groups) with female undergraduate students (Reas et al., 2002; Reas et al., 2006). Scores on the BCQ range from 23 to 115. The BCQ has a cut-off score set at one standard deviation above the score for college females (score of 72). 1.3.5. Dieting brochure questionnaire The dieting brochure questionnaire consisted of 31 items, rated on a 5-point scale anchored with the words ‘‘disagree,’’ ‘‘somewhat disagree,’’ ‘‘not sure/don’t know,’’ ‘‘somewhat agree,’’ and ‘‘agree.’’ The items were scored from one to five, with five representing greater agreement. Most of the items addressed the format (e.g., the brochure was easy to read) and informativeness (e.g., the brochure was informative) of the brochures; 3 items, however, were used to assess desire to change eating and exercise behaviour (e.g., the brochure made you want to diet) and 6 items were designed to assess level of health anxiety in response to the brochure (e.g., the information caused you to worry about illness). Internal consistency was adequate for these two scales, .68 for Desire to Diet/Exercise and .75 for Health Anxiety.
2. Results 2.1. Health anxiety scores Individuals were classified into health anxious and non-health anxious groups based on a median split (scores below 38 were low health anxious and those 38 or above were high health anxious). On average, the low health anxious group (n = 58) had a score of 28.09 (SD = 6.26) on the IAS and the high health anxious group (n = 64) had a score of 50.47 (SD = 8.66) on the IAS. Thirty two individuals in the high health anxious group scored above the cut-off score of 50 that has been used to identify individuals who have significant health anxiety (Bouman & Visser, 1998).
324
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
2.2. Correlational analyses Correlations between the IAS and the EAT-26 and BCQ scales are presented in Table 1. The IAS total score had a moderate positive correlation with both the EAT-26 and the BCQ total scores. Examination of subscales showed that the IAS Fear of Illness and Pain Subscale had strong correlations with all of the EAT-26 and BCQ subscales, with the exception of the EAT Oral Control subscale. The IAS Disease Conviction subscale was only correlated with the BCQ subscales and not the EAT 26 subscales. The IAS Effect of Symptoms subscale correlated with the EAT-26 Dieting subscale and all of the BCQ subscales. The IAS Treatment Seeking subscale had the lowest and fewest correlations with the subscales, correlating weakly with the EAT-26 Dieting subscale and the BCQ Checking of Appearance subscale. 2.3. Analysis of variance Prior to conducting this analysis, we examined whether the low and high health anxiety groups (formed on the basis of the median split of the IAS) differed on age or BMI. No significant differences were found. Analysis of variance (ANOVA) was used to examine whether those varying in health anxiety or type of dieting information differed in how they responded to the brochure. Two 2 (low or high health anxiety) · 2 (positive or negative dieting information) ANOVAs were examined; one focused on concern about health, and the other desire to diet and exercise. The results revealed main effects for health anxiety (see Table 2 to examine the means and standard deviations illustrating the main effect) showing that after reading information about dieting, individuals who were high on health anxiety expressed significantly greater worry about their health than individuals low on health anxiety, F(1, 121) = 22.01, p < .0001. They also described having a greater interest in dieting and exercising than those who were low in health anxiety, F(1, 121) = 13.97, p < .0001. There was no main effect for the type of dieting information. The hypothesized interaction between health anxiety and type of dieting information was also not observed. That is, no support was found for the prediction that non-health anxious individuals
Table 1 Correlations between IAS subscales and EAT-26 and BCQ subscales
EAT-26 Total EAT-26 Dieting EAT-26 Food Preoccupation EAT-26 Oral Control BCQ Total BCQ Appearance BCQ Body Parts BCQ Idiosyncratic Checking Note: n = 122. * p < .05. ** p < .01.
IAS Total
IAS Fear
IAS Symptom Effects
IAS Treatment Seeking
IAS Disease Conviction
.33** .33** .26** .10 .40** .40** .35** .34**
.31** .28** .30** .10 .37** .35** .34** .30**
.20* .21* .12 .09 .27** .26** .20* .29**
.18 .19* .07 .05 .20* .20* .17 .18
.18 .17 .14 .09 .29** .27** .25** .29**
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
325
Table 2 Differences between individuals low and high on health anxiety in response to reading information about the effects of dieting
Concern about Health Desire to Diet and Exercise
Low Health Anxiety (n = 58)
High Health Anxiety (n = 64)
M
SD
M
SD
2.07 2.45
.54 1.07
2.60 3.16
.67 1.00
would respond with lower anxiety in response to positive versus negative information about dieting.
3. Discussion The purpose of this investigation was to systematically explore the relationship between health anxiety and eating patterns and shape-related body checking. Confirming clinical observations and anecdotal reports, positive correlations between health anxiety and eating patterns were observed suggesting that individuals who are worried about their health are more likely to report dieting as well as food preoccupation. They did not, however, show increased scores on the subscale reflecting oral control (e.g., items reflect avoidance of eating) which is characteristic of those with anorexia nervosa (Garner et al., 1982). Health anxiety was also correlated with shape-related body checking, including checking of general appearance, checking of body parts and idiosyncratic body checking. These results are important and suggest that dieting and body checking may have been overlooked in previous research on health anxiety. Within the framework of cognitive-behavioural theory, it is possible that dieting and body checking represent strategies to manage health anxiety. This is not meant to suggest that these are necessarily negative strategies, but further research is required to understand how health anxiety specifically may be a trigger of shape-related body checking, food preoccupation and dieting. Previous research suggests that trait anxiety and negative affect can trigger dieting behaviours (Miller et al., 2006) and body checking (Reas et al., 2006) and the current research extends this research by showing an association between health specific anxiety and these behaviours. An interesting question that emerges from the study is at what point does health anxiety trigger eating patterns and body checking that are of clinical concern? It also appears that health anxiety, and not associated aspects of the construct, accounts for the relationships with dieting, food preoccupation and body checking. Examination of the health anxiety subscale correlations showed that it was the Fear of Illness and Pain subscale of the IAS that was most strongly related to eating patterns (i.e., dieting, food preoccupation) and shape-related body checking (i.e., appearance checking, body parts checking, idiosyncratic checking). The IAS Disease Conviction was only related to body checking subscales. The IAS Effects of Symptoms subscale correlated with body checking and dieting. The IAS Treatment Seeking scale was only weakly related to dieting and checking of one’s appearance. Examination of the pattern of
326
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
correlations is important since it confirms that it is anxiety about illness, and not the other secondary components of health anxiety (e.g., seeking treatment, effects of symptoms, disease conviction) that strongly relate to eating patterns and shape-related body checking. In an attempt to further enhance our understanding of the effects of dieting information on health anxiety, we had participants read either negative or positive information about dieting and then examined concern about health and interest in dieting and exercising. It is very common for individuals to be confronted with both positive and negative information on dieting in the media (Brownell & Rodin, 1994) and based on the CB theory of health anxiety, we predicted that health anxiety may impact on how threatening this information is perceived to be. We did not, however, find that participants responded differentially to the positive versus negative information about dieting. We had anticipated that health anxious individuals would find all information about dieting to be anxiety provoking and that only non-health anxious individuals would differentially respond to the information (e.g., respond with some anxiety to negative information about dieting, but not to positive information about dieting). In contrast to our hypothesis, we found, that individuals who were high on health anxiety compared to low on health anxiety responded with greater concern about their health and greater interest in dieting and exercising regardless of the information they were given. There were a number of limitations to the study. The data was obtained from university female students who agreed to take part in the study for a research credit. The data might not reveal the same main effects if the study were conducted with a clinical population. The study may also have been limited in its use of self-report measures because such measures are reliant on participants answering honestly and individuals may under report their weight and negative eating behaviours (McCabe, McFarlane, Polivy, & Olmsted, 2001). It is also possible that the effects may have been stronger had the brochures contained stronger positive and negative information about dieting. There were ethical constraints, however, on what we were comfortable presenting in the brochures. Furthermore, a larger sample may have been better able to detect an effect. Finally, although the dieting brochure scales were internally consistent, evidence of the validity of the scales was limited to face validity. The present findings suggest that further research into the relationship among health anxiety, eating patterns and body checking is clearly warranted. It would be of interest to conduct this study within a clinical population to determine if the results generalize to those who have clinical disorders. Furthermore, it would be valuable to explore eating patterns with strategies such as food diaries. Longitudinal research that examines how dieting and body checking are related to health anxiety would be valuable in exploring the causal relationships involved. What comes first, health anxiety or dieting? Future research might also include examining whether the greater desire to diet and exercise in individuals with high levels of health anxiety translates into actual changes in behaviour. Also, as stated earlier, it is important to disentangle at what point health anxiety may lead to dysfunctional dieting behaviour and body checking. Not all dieting is dysfunctional and also not all health anxiety is inappropriate. With further research, it is possible that dieting and body checking may become important targets in the treatment of health anxiety. In the treatment of health anxiety at the present time there is a focus on identifying and changing behaviours that are avoided because they trigger health anxiety (e.g., avoiding hospitals, information on disease) or behaviours that are exhibited in order to reassure the individual that they are healthy (e.g., medical appointments, body checking). It is
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
327
possible that the dieting and body checking represent other such behaviours that need to be assessed and explored in therapy for severe health anxiety.
Acknowledgements We would like to acknowledge Terry-Lynn Sullivan and Kerry Spice for their assistance with data collection along with Jennifer Amy Janzen for her assistance with manuscript preparation. We would also like to acknowledge the reviewers, who provided very helpful feedback and suggestions to improve the manuscript.
References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. Text rev.). Washington, DC: Author. Appleton, K. M., & McGowan, L. (2006). The relationship between restrained eating and poor psychological health is moderated by pleasure normally associated with eating. Eating Behaviors, 7, 342–347. Asmundson, G. J. G., Taylor, S., & Cox, B. J. (2001). Health anxiety: clinical and research perspectives on hypochondriasis and related disorders. London: Wiley. Bouman, T. K., & Visser, S. (1998). Cognitive and behavioral treatment of hypochondriasis. Psychotherapy and Psychosomatics, 67, 214–221. Brownell, K. D., & Rodin, J. (1994). The dieting maelstrom: is it possible and advisable to lose weight? American Psychologist, 49, 781–791. Bulik, C. M., Sullivan, P. F., Carter, F. A., & Joyce, P. R. (1996). Lifetime anxiety disorders in women with bulimia nervosa. Comprehensive Psychiatry, 37, 368–374. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes test: psychometric features and clinical correlates. Psychological Medicine, 12, 871–878. Hadjistavropoulos, H. D., Craig, K. D., & Hadjistavropoulos, T. (1998). Cognitive and behavioral responses to illness information: the role of health anxiety. Behaviour Research and Therapy, 36, 149–164. Hadjistavropoulos, H. D., Frombach, I. K., & Asmundson, G. J. G. (1999). Exploratory and confirmatory factor analytic investigations of the illness attitudes scale in a nonclinical sample. Behaviour Research and Therapy, 37, 671–684. Hadjistavropoulos, H. D., Hadjistavropoulos, T., & Quine, A. (2000). Health anxiety moderates the effects of distraction versus attention to pain. Behaviour Research and Therapy, 38, 425–438. Haenen, M. A., de Jong, P. J., Schmidt, A. J. M., Stevens, S., & Visser, L. (2000). Hypochondriacs’ estimation of negative outcomes: domain-specificity and responsiveness to reassuring and alarming information. Behaviour Research and Therapy, 38, 819–833. Kellner, R., Abbott, P., Winslow, W. W., & Pathak, D. (1987). Fears, beliefs, and attitudes in DSM-III hypochondriasis. The Journal of Nervous and Mental Disease, 175, 20–25. McCabe, R. E., McFarlane, T., Polivy, J., & Olmsted, M. P. (2001). Eating disorders, dieting, and the accuracy of selfreported weight. International Journal of Eating Disorders, 29, 59–64. Miller, J. L., Scmidt, L. A., Vaillancourt, T., McDougall, P., & Laliberte, M. (2006). Neuroticism and introversion: a risky combination for disordered eating among a non-clinical sample of undergraduate women. Eating Behaviors, 7, 69–78. Mintz, L. B., & O’Halloran, M. S. (2000). The eating attitudes test: validation with DSM-IV eating disorder criteria. Journal of Personality Assessment, 74, 489–503. Reas, D. L., Grilo, C. M., Masheb, R. M., & Wilson, T. G. (2005). Body checking and avoidance in overweight patients with binge eating disorder. International Journal of Eating Disorders, 37, 342–346.
328
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
Reas, D. L., Whisenhunt, B. L., Netemeyer, R., & Williamson, D. A. (2002). Development of the body checking questionnaire: a self-report measure of body checking behaviors. International Journal of Eating Disorders, 31, 324–333. Reas, D. L., White, M. A., & Grilo, C. M. (2006). Body checking questionnaire: psychometric properties and clinical correlates in obese men and women with binge eating disorder. International Journal of Eating Disorders, 39, 326–331. Salkovskis, P. M., & Warwick, H. M. (1986). Morbid preoccupation, health anxiety and reassurance: a cognitivebehavioural approach to hypochondriasis. Behaviour Research and Therapy, 24, 597–602. Stewart, S., & Watt, M. (2001). Assessment of health anxiety. In G. J. G. Asmundson, S. Taylor, & B. J. Cox (Eds.), Health anxiety: clinical and research perspectives on hypochondriasis and related disorders (pp. 95–131). London: Wiley. Stewart, S., & Watt, M. (2000). Illness attitudes scale dimensions and their associations with anxiety-related constructs in a non-clinical sample. Behavior Research and Therapy, 38, 83–99. Taylor, S., & Asmundson, G. J. G. (2004). Treating health anxiety. A cognitive-behavioral approach. New York: Guilford.
Does anxiety about health influence eating patterns and shape-related body checking among females? Heather Hadjistavropoulos *, Brandy Lawrence Heather Hadjistavropoulos, Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, Canada SK S4S 0A2 Received 13 April 2006; received in revised form 7 November 2006; accepted 29 November 2006 Available online 26 January 2007
Abstract In clinical practice, patients who have elevated worries about health often report a desire to diet and a preoccupation with body shape; furthermore, they report that information about dieting can trigger significant health anxiety. To date, there has been no research that has systematically investigated the relationships among elevated health anxiety, eating patterns, and body shape preoccupation. In this study, 122 female participants completed measures of health anxiety, eating patterns, and body checking. Participants were also randomly given either positive (n = 59) or negative (n = 63) information about the effects of dieting on health allowing us to examine the consequences of receiving differential dieting information on health anxious and non-health anxious individuals. Health anxiety was positively correlated with dieting and food preoccupation; it was also correlated with body checking to assess shape. Analysis of variance showed that after reading both positive and negative information about dieting, individuals highly health anxious experienced greater concern about their health and a greater desire to diet and exercise than individuals with lower levels of health anxiety. Further research should explore dieting and body shape checking as behavioural responses to health anxiety, and, clinically, practitioners should consider monitoring these behaviours when assessing and treating health anxiety. 2006 Elsevier Ltd. All rights reserved. Keywords: Health anxiety; Dieting; Food preoccupation; Body checking
*
Corresponding author. Tel.: +1 306 585 5133; fax: +1 306 585 5429. E-mail address: [email protected] (H. Hadjistavropoulos).
0191-8869/$ - see front matter 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2006.11.021
320
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
0. Introduction Anecdotally, those who are worried about their health frequently report that anxiety about health can initiate a change in eating patterns, such as dieting or preoccupation with food. Health anxiety is defined as health-related fears and beliefs that one’s physical well-being is threatened (Asmundson, Taylor, & Cox, 2001). Health anxiety ranges on a continuum from mild to severe, is normally distributed in the population and in its extreme form is apparent in those with mental health disorders such as hypochondriasis and panic disorder (Taylor & Asmundson, 2004). Health anxiety is clinically important even when patients do not meet diagnostic criteria for a mental disorder, and can have a significant impact on emotional well-being and health behaviour (Hadjistavropoulos, Craig, & Hadjistavropoulos, 1998). In primary care outpatients, severe health anxiety occurs in 2–7% of the population (American Psychiatric Association, 2000) and, in the community, prevalence rates for severe health anxiety range from 1.5% to 4.5% (Asmundson et al., 2001). The cognitive-behavioural model of health anxiety (Salkovskis & Warwick, 1986) postulates that cognitions (e.g., the belief that physical symptoms always indicate a serious illness), formulated based on past experiences, are central in the development of health anxiety. Health anxiety is then spawned by a combination of dysfunctional health beliefs and critical incidents (e.g., physical symptoms, information on health). Information about dieting could potentially trigger health anxiety although this has not been investigated. Once present, health anxiety results in catastrophic thoughts about health, negative emotion, and an attentional focus on health-related information (Salkovskis & Warwick, 1986). Individuals also demonstrate protective behaviours designed to reduce health anxiety, such as avoiding illness-related information or seeking medical reassurance (Taylor & Asmundson, 2004). Dieting and body checking could be further behaviours designed to reduce health anxiety, although again this has not been investigated. Body checking involves examining one’s overall appearance or inspecting specific body parts. It has been hypothesized that checking behaviours resemble compulsions and may initially serve to reassure the individual that no problem exists; body checking, however, in the longer term paradoxically may serve to increase rather than decrease anxiety (Reas, Whisenhunt, Netemeyer, & Williamson, 2002). Recently there has been an upsurge of research conducted on health anxiety (Asmundson et al., 2001), but to date the relationship between health anxiety and eating patterns and shape-related body checking has not been explored. However, a review of literature on anxiety in general suggests that a dual causal pathway may exist between anxiety and eating patterns and shape-related body checking. Research shows, for instance, that trait anxiety is associated with dieting, food preoccupation and restrained eating in non-clinical samples (Miller, Scmidt, Vaillancourt, McDougall, & Laliberte, 2006); negative affect is also associated with increased body checking (Reas, White, & Grilo, 2006). Dieting and body checking also appear to trigger variations in state anxiety (e.g., Appleton & McGowan, 2006; Reas, Grilo, Masheb, & Wilson, 2005). In the clinical realm, research on co-morbidity in eating disorders indicates that a high proportion of individuals with anorexia and bulimia nervosa suffer from some type of anxiety disorder (Bulik, Sullivan, Carter, & Joyce, 1996). The purpose of this study was to expand on this previous body of research and explore the relationship between anxiety specifically focused on health, and eating patterns and body checking. To further understand the relationship between health anxiety and dieting, this study sought to explore whether positive versus negative information about dieting had a different impact on indi-
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
321
viduals who were health anxious versus non-health anxious. It is common to find contradictory information on dieting in the media. On the one hand, dieting is described as reducing morbidity and mortality. On the other hand, however, increasingly there are reports that diets are harmful, with weight cycling in particular being associated in some studies with progressive difficulties losing weight, an increased preference for dietary fat, cardiovascular disease, binge eating and depression (Brownell & Rodin, 1994). The cognitive-behavioural theory of health anxiety (Salkovskis & Warwick, 1986) and research findings (Haenen, de Jong, Schmidt, Stevens, & Visser, 2000) on health anxiety in general led us to predict that health anxiety would have moderate to strong positive relationships with body checking and dieting behaviours. Furthermore, we predicted that health anxious individuals would interpret all information about dieting, regardless of whether it was positive or negative in nature, as threatening. In this way, health anxious individuals were expected to report greater anxiety in response to this information compared to non-health anxious individuals. Individuals who were non-health anxious, on the other hand, were expected to respond with anxiety to information on the negative effects of dieting, but not the positive effects of dieting; thus, their level of anxiety would be more consistent with the information they received.
1. Method 1.1. Sample A total of 122 females participated in this study with an average age of 19.63 years (SD = 2.65). The average reported BMI was 21.98 (SD = 3.76). Participants were divided into high or low levels of health anxious groups by performing a median split on the Illness Attitudes Scale (Kellner, Abbott, Winslow, & Pathak, 1987) total score (scores of 37 or lower were coded as low and scores of 38 or higher were coded as high). Previous research shows that deriving groups of health anxious and non-health anxious participants in this way results in meaningful differences between groups (Hadjistavropoulos, Hadjistavropoulos, & Quine, 2000). Students were randomly assigned to receive either positive (n = 59) or negative information (n = 63) about dieting, thus creating a 2 (low versus high health anxiety) · 2 (positive versus negative information about dieting) design. Based on a power analysis, we determined that approximately 30 participants were needed in each group. With random assignment and median split, there were 29 individuals in the low health anxious positive dieting information group, 29 individuals in the low health anxious negative dieting information group, 30 individuals in the high health anxious positive dieting information group and 34 individuals in the high health anxious negative dieting information group. 1.2. Procedure The study was posted on the Psychology Participant Bulletin Board at the University of Regina, Saskatchewan and students signed up to complete the study during various time slots. Participants were administered the Illness Attitudes Scale (Kellner et al., 1987), Eating Attitudes Test-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982), and Body Checking Questionnaire (Reas et al., 2002). Students were then randomly assigned to receive either positive or negative information about dieting.
322
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
Participants read through a brochure and then responded to a questionnaire about the brochure. They were told the brochure was created to educate first year students about dieting. Due to concerns about response bias, participants were not informed that we were studying their level of anxiety in response to varying information about dieting. In the positive dieting condition, participants were administered a brochure that described the positive consequences of dieting, including reduced cholesterol levels, risk of diabetes, and cardiovascular disease (Brownell & Rodin, 1994). In the negative dieting condition, the brochure emphasized the negative consequences of dieting that also have been presented in the literature. In particular, in the negative dieting condition we highlighted how dieting has been associated with an increased risk of being overweight and that dieting, resulting in weight fluctuations, has been associated with increased risk of developing cardiovascular disease and hypertension (Brownell & Rodin, 1994). Both brochures were matched for word and picture content, to ensure that the only difference between the two was the negative versus positive information presented. After reading the brochure, participants were administered a questionnaire developed for this study asking about responses to the dieting brochure. Participants were then thoroughly debriefed as to the true nature of the study using a debriefing script. Participants were given the name of a psychologist to contact if they felt they needed to talk to someone about the study. Ethical approval for the study was acquired from the Institutional Review Board. 1.3. Measures 1.3.1. Demographic questions The following background questions were asked of participants: age, height, and weight. From this information, each participant’s body mass index (BMI) was calculated (weight in kilograms divided by height in meters squared). 1.3.2. Illness attitudes scale (IAS) The IAS is a 27 item instrument with items rated on a 0–4 scale (Kellner et al., 1987). The scale was devised to assess fears, beliefs, and attitudes associated with hypochondriasis and abnormal illness behaviours. Nine subscales (3 items each) were initially identified, but factor analysis with students suggests that a hierarchical model is more appropriate, with four lower order factors loading on a single higher order factor. The four factors measure: (1) fear of illness and pain, (2) effects of symptoms on functioning, (3) treatment seeking behaviour, and (4) disease conviction (e.g., certainty that one has a disease); (Hadjistavropoulos, Frombach, & Asmundson, 1999). The IAS has good test–retest reliability, convergent validity with other measures of health anxiety, and known groups validity (Stewart & Watt, 2001). In a sample of 156 females and 41 male undergraduates, Stewart and Watt (2000) found that the IAS correlates in predictable ways with other measures of anxiety. Scores can range from 0 to 108 with patients who have a DSM-IV diagnosis of hypochondriasis typically obtaining scores above 50 (Bouman & Visser, 1998). 1.3.3. Eating Attitudes Test-26 (EAT-26) The EAT-26 is a 26-item questionnaire that is designed to reflect a range of behaviours including dieting (e.g., eating diet foods, being aware of calorie content of foods), food preoccupation (e.g., preoccupied with food, impulse to vomit after meals), and oral control (e.g., avoid eating
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
323
when hungry, feeling that others would prefer the individual to eat more) (Garner et al., 1982). The participant is required to judge whether each item applies to them ‘‘always,’’ ‘‘very often,’’ ‘‘often,’’ ‘‘somewhat,’’ ‘‘rarely,’’ and ‘‘never.’’ Extreme responses (‘‘always’’) are rated as a 3 and less extreme responses (‘‘very often’’ and ‘‘often’’) are rated as 2 or 1; the lowest three ratings (‘‘somewhat,’’ ‘‘rarely,’’ and ‘‘never’’) are given a score of 0. Possible scores on the EAT-26 range from 0 to 78 with females with eating disorders often obtaining scores above 36 (Garner et al., 1982). The EAT-26 is a reliable (e.g., internal consistency, test–retest reliability) and valid measure (correlates with other measures, identifies individuals with disordered eating) of dysfunctional eating attitudes (Mintz & O’Halloran, 2000) among female university students. 1.3.4. Body checking questionnaire (BCQ) The BCQ is a recently developed 23-item measure of the body checking behaviours associated with body shape concerns (Reas et al., 2002). The items are scored on a 5-point Likert scale, with responses ranging from 1 (never) to 5 (very often). The BCQ is composed of three subscales measuring checking of overall appearance (e.g., check my reflection in a mirror), checking of specific body parts (e.g., pinch my stomach, upper arms), and idiosyncratic checking rituals (e.g., check to see how ring fits) and has been found to be reliable (e.g., internally consistent, adequate test–rest reliability) and valid (e.g., correlated with related measures, differentiates between known groups) with female undergraduate students (Reas et al., 2002; Reas et al., 2006). Scores on the BCQ range from 23 to 115. The BCQ has a cut-off score set at one standard deviation above the score for college females (score of 72). 1.3.5. Dieting brochure questionnaire The dieting brochure questionnaire consisted of 31 items, rated on a 5-point scale anchored with the words ‘‘disagree,’’ ‘‘somewhat disagree,’’ ‘‘not sure/don’t know,’’ ‘‘somewhat agree,’’ and ‘‘agree.’’ The items were scored from one to five, with five representing greater agreement. Most of the items addressed the format (e.g., the brochure was easy to read) and informativeness (e.g., the brochure was informative) of the brochures; 3 items, however, were used to assess desire to change eating and exercise behaviour (e.g., the brochure made you want to diet) and 6 items were designed to assess level of health anxiety in response to the brochure (e.g., the information caused you to worry about illness). Internal consistency was adequate for these two scales, .68 for Desire to Diet/Exercise and .75 for Health Anxiety.
2. Results 2.1. Health anxiety scores Individuals were classified into health anxious and non-health anxious groups based on a median split (scores below 38 were low health anxious and those 38 or above were high health anxious). On average, the low health anxious group (n = 58) had a score of 28.09 (SD = 6.26) on the IAS and the high health anxious group (n = 64) had a score of 50.47 (SD = 8.66) on the IAS. Thirty two individuals in the high health anxious group scored above the cut-off score of 50 that has been used to identify individuals who have significant health anxiety (Bouman & Visser, 1998).
324
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
2.2. Correlational analyses Correlations between the IAS and the EAT-26 and BCQ scales are presented in Table 1. The IAS total score had a moderate positive correlation with both the EAT-26 and the BCQ total scores. Examination of subscales showed that the IAS Fear of Illness and Pain Subscale had strong correlations with all of the EAT-26 and BCQ subscales, with the exception of the EAT Oral Control subscale. The IAS Disease Conviction subscale was only correlated with the BCQ subscales and not the EAT 26 subscales. The IAS Effect of Symptoms subscale correlated with the EAT-26 Dieting subscale and all of the BCQ subscales. The IAS Treatment Seeking subscale had the lowest and fewest correlations with the subscales, correlating weakly with the EAT-26 Dieting subscale and the BCQ Checking of Appearance subscale. 2.3. Analysis of variance Prior to conducting this analysis, we examined whether the low and high health anxiety groups (formed on the basis of the median split of the IAS) differed on age or BMI. No significant differences were found. Analysis of variance (ANOVA) was used to examine whether those varying in health anxiety or type of dieting information differed in how they responded to the brochure. Two 2 (low or high health anxiety) · 2 (positive or negative dieting information) ANOVAs were examined; one focused on concern about health, and the other desire to diet and exercise. The results revealed main effects for health anxiety (see Table 2 to examine the means and standard deviations illustrating the main effect) showing that after reading information about dieting, individuals who were high on health anxiety expressed significantly greater worry about their health than individuals low on health anxiety, F(1, 121) = 22.01, p < .0001. They also described having a greater interest in dieting and exercising than those who were low in health anxiety, F(1, 121) = 13.97, p < .0001. There was no main effect for the type of dieting information. The hypothesized interaction between health anxiety and type of dieting information was also not observed. That is, no support was found for the prediction that non-health anxious individuals
Table 1 Correlations between IAS subscales and EAT-26 and BCQ subscales
EAT-26 Total EAT-26 Dieting EAT-26 Food Preoccupation EAT-26 Oral Control BCQ Total BCQ Appearance BCQ Body Parts BCQ Idiosyncratic Checking Note: n = 122. * p < .05. ** p < .01.
IAS Total
IAS Fear
IAS Symptom Effects
IAS Treatment Seeking
IAS Disease Conviction
.33** .33** .26** .10 .40** .40** .35** .34**
.31** .28** .30** .10 .37** .35** .34** .30**
.20* .21* .12 .09 .27** .26** .20* .29**
.18 .19* .07 .05 .20* .20* .17 .18
.18 .17 .14 .09 .29** .27** .25** .29**
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
325
Table 2 Differences between individuals low and high on health anxiety in response to reading information about the effects of dieting
Concern about Health Desire to Diet and Exercise
Low Health Anxiety (n = 58)
High Health Anxiety (n = 64)
M
SD
M
SD
2.07 2.45
.54 1.07
2.60 3.16
.67 1.00
would respond with lower anxiety in response to positive versus negative information about dieting.
3. Discussion The purpose of this investigation was to systematically explore the relationship between health anxiety and eating patterns and shape-related body checking. Confirming clinical observations and anecdotal reports, positive correlations between health anxiety and eating patterns were observed suggesting that individuals who are worried about their health are more likely to report dieting as well as food preoccupation. They did not, however, show increased scores on the subscale reflecting oral control (e.g., items reflect avoidance of eating) which is characteristic of those with anorexia nervosa (Garner et al., 1982). Health anxiety was also correlated with shape-related body checking, including checking of general appearance, checking of body parts and idiosyncratic body checking. These results are important and suggest that dieting and body checking may have been overlooked in previous research on health anxiety. Within the framework of cognitive-behavioural theory, it is possible that dieting and body checking represent strategies to manage health anxiety. This is not meant to suggest that these are necessarily negative strategies, but further research is required to understand how health anxiety specifically may be a trigger of shape-related body checking, food preoccupation and dieting. Previous research suggests that trait anxiety and negative affect can trigger dieting behaviours (Miller et al., 2006) and body checking (Reas et al., 2006) and the current research extends this research by showing an association between health specific anxiety and these behaviours. An interesting question that emerges from the study is at what point does health anxiety trigger eating patterns and body checking that are of clinical concern? It also appears that health anxiety, and not associated aspects of the construct, accounts for the relationships with dieting, food preoccupation and body checking. Examination of the health anxiety subscale correlations showed that it was the Fear of Illness and Pain subscale of the IAS that was most strongly related to eating patterns (i.e., dieting, food preoccupation) and shape-related body checking (i.e., appearance checking, body parts checking, idiosyncratic checking). The IAS Disease Conviction was only related to body checking subscales. The IAS Effects of Symptoms subscale correlated with body checking and dieting. The IAS Treatment Seeking scale was only weakly related to dieting and checking of one’s appearance. Examination of the pattern of
326
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
correlations is important since it confirms that it is anxiety about illness, and not the other secondary components of health anxiety (e.g., seeking treatment, effects of symptoms, disease conviction) that strongly relate to eating patterns and shape-related body checking. In an attempt to further enhance our understanding of the effects of dieting information on health anxiety, we had participants read either negative or positive information about dieting and then examined concern about health and interest in dieting and exercising. It is very common for individuals to be confronted with both positive and negative information on dieting in the media (Brownell & Rodin, 1994) and based on the CB theory of health anxiety, we predicted that health anxiety may impact on how threatening this information is perceived to be. We did not, however, find that participants responded differentially to the positive versus negative information about dieting. We had anticipated that health anxious individuals would find all information about dieting to be anxiety provoking and that only non-health anxious individuals would differentially respond to the information (e.g., respond with some anxiety to negative information about dieting, but not to positive information about dieting). In contrast to our hypothesis, we found, that individuals who were high on health anxiety compared to low on health anxiety responded with greater concern about their health and greater interest in dieting and exercising regardless of the information they were given. There were a number of limitations to the study. The data was obtained from university female students who agreed to take part in the study for a research credit. The data might not reveal the same main effects if the study were conducted with a clinical population. The study may also have been limited in its use of self-report measures because such measures are reliant on participants answering honestly and individuals may under report their weight and negative eating behaviours (McCabe, McFarlane, Polivy, & Olmsted, 2001). It is also possible that the effects may have been stronger had the brochures contained stronger positive and negative information about dieting. There were ethical constraints, however, on what we were comfortable presenting in the brochures. Furthermore, a larger sample may have been better able to detect an effect. Finally, although the dieting brochure scales were internally consistent, evidence of the validity of the scales was limited to face validity. The present findings suggest that further research into the relationship among health anxiety, eating patterns and body checking is clearly warranted. It would be of interest to conduct this study within a clinical population to determine if the results generalize to those who have clinical disorders. Furthermore, it would be valuable to explore eating patterns with strategies such as food diaries. Longitudinal research that examines how dieting and body checking are related to health anxiety would be valuable in exploring the causal relationships involved. What comes first, health anxiety or dieting? Future research might also include examining whether the greater desire to diet and exercise in individuals with high levels of health anxiety translates into actual changes in behaviour. Also, as stated earlier, it is important to disentangle at what point health anxiety may lead to dysfunctional dieting behaviour and body checking. Not all dieting is dysfunctional and also not all health anxiety is inappropriate. With further research, it is possible that dieting and body checking may become important targets in the treatment of health anxiety. In the treatment of health anxiety at the present time there is a focus on identifying and changing behaviours that are avoided because they trigger health anxiety (e.g., avoiding hospitals, information on disease) or behaviours that are exhibited in order to reassure the individual that they are healthy (e.g., medical appointments, body checking). It is
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
327
possible that the dieting and body checking represent other such behaviours that need to be assessed and explored in therapy for severe health anxiety.
Acknowledgements We would like to acknowledge Terry-Lynn Sullivan and Kerry Spice for their assistance with data collection along with Jennifer Amy Janzen for her assistance with manuscript preparation. We would also like to acknowledge the reviewers, who provided very helpful feedback and suggestions to improve the manuscript.
References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. Text rev.). Washington, DC: Author. Appleton, K. M., & McGowan, L. (2006). The relationship between restrained eating and poor psychological health is moderated by pleasure normally associated with eating. Eating Behaviors, 7, 342–347. Asmundson, G. J. G., Taylor, S., & Cox, B. J. (2001). Health anxiety: clinical and research perspectives on hypochondriasis and related disorders. London: Wiley. Bouman, T. K., & Visser, S. (1998). Cognitive and behavioral treatment of hypochondriasis. Psychotherapy and Psychosomatics, 67, 214–221. Brownell, K. D., & Rodin, J. (1994). The dieting maelstrom: is it possible and advisable to lose weight? American Psychologist, 49, 781–791. Bulik, C. M., Sullivan, P. F., Carter, F. A., & Joyce, P. R. (1996). Lifetime anxiety disorders in women with bulimia nervosa. Comprehensive Psychiatry, 37, 368–374. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes test: psychometric features and clinical correlates. Psychological Medicine, 12, 871–878. Hadjistavropoulos, H. D., Craig, K. D., & Hadjistavropoulos, T. (1998). Cognitive and behavioral responses to illness information: the role of health anxiety. Behaviour Research and Therapy, 36, 149–164. Hadjistavropoulos, H. D., Frombach, I. K., & Asmundson, G. J. G. (1999). Exploratory and confirmatory factor analytic investigations of the illness attitudes scale in a nonclinical sample. Behaviour Research and Therapy, 37, 671–684. Hadjistavropoulos, H. D., Hadjistavropoulos, T., & Quine, A. (2000). Health anxiety moderates the effects of distraction versus attention to pain. Behaviour Research and Therapy, 38, 425–438. Haenen, M. A., de Jong, P. J., Schmidt, A. J. M., Stevens, S., & Visser, L. (2000). Hypochondriacs’ estimation of negative outcomes: domain-specificity and responsiveness to reassuring and alarming information. Behaviour Research and Therapy, 38, 819–833. Kellner, R., Abbott, P., Winslow, W. W., & Pathak, D. (1987). Fears, beliefs, and attitudes in DSM-III hypochondriasis. The Journal of Nervous and Mental Disease, 175, 20–25. McCabe, R. E., McFarlane, T., Polivy, J., & Olmsted, M. P. (2001). Eating disorders, dieting, and the accuracy of selfreported weight. International Journal of Eating Disorders, 29, 59–64. Miller, J. L., Scmidt, L. A., Vaillancourt, T., McDougall, P., & Laliberte, M. (2006). Neuroticism and introversion: a risky combination for disordered eating among a non-clinical sample of undergraduate women. Eating Behaviors, 7, 69–78. Mintz, L. B., & O’Halloran, M. S. (2000). The eating attitudes test: validation with DSM-IV eating disorder criteria. Journal of Personality Assessment, 74, 489–503. Reas, D. L., Grilo, C. M., Masheb, R. M., & Wilson, T. G. (2005). Body checking and avoidance in overweight patients with binge eating disorder. International Journal of Eating Disorders, 37, 342–346.
328
H. Hadjistavropoulos, B. Lawrence / Personality and Individual Differences 43 (2007) 319–328
Reas, D. L., Whisenhunt, B. L., Netemeyer, R., & Williamson, D. A. (2002). Development of the body checking questionnaire: a self-report measure of body checking behaviors. International Journal of Eating Disorders, 31, 324–333. Reas, D. L., White, M. A., & Grilo, C. M. (2006). Body checking questionnaire: psychometric properties and clinical correlates in obese men and women with binge eating disorder. International Journal of Eating Disorders, 39, 326–331. Salkovskis, P. M., & Warwick, H. M. (1986). Morbid preoccupation, health anxiety and reassurance: a cognitivebehavioural approach to hypochondriasis. Behaviour Research and Therapy, 24, 597–602. Stewart, S., & Watt, M. (2001). Assessment of health anxiety. In G. J. G. Asmundson, S. Taylor, & B. J. Cox (Eds.), Health anxiety: clinical and research perspectives on hypochondriasis and related disorders (pp. 95–131). London: Wiley. Stewart, S., & Watt, M. (2000). Illness attitudes scale dimensions and their associations with anxiety-related constructs in a non-clinical sample. Behavior Research and Therapy, 38, 83–99. Taylor, S., & Asmundson, G. J. G. (2004). Treating health anxiety. A cognitive-behavioral approach. New York: Guilford.