Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients

J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

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Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients Joelle N. Soucy, M.A., Heather D. Hadjistavropoulos, Ph.D. * Department of Psychology, University of Regina, Regina, Canada

a r t i c l e i n f o

a b s t r a c t

Article history: Received 25 October 2016 Received in revised form 26 January 2017 Accepted 17 February 2017 Available online 20 February 2017

Background & objectives: While cognitive behaviour therapy (CBT) is an established treatment for health anxiety, there are barriers to service access. Internet-delivered cognitive behaviour therapy (ICBT) has demonstrated effectiveness and has the potential to improve access to treatment. Nevertheless, it is unknown how patients perceive ICBT relative to other interventions for health anxiety and what factors predict ICBT acceptability. This study investigated these questions. Methods: Primary care patients (N ¼ 116) who reported elevated levels of health anxiety were presented three treatment vignettes that each described a different protocol for health anxiety (i.e., medication, CBT, ICBT). Acceptability and credibility of the treatments were assessed following the presentation of each vignette. Participants then ranked the three treatments and provided a rational for their preferences. Results: The treatments were similarly rated as moderately acceptable. Relative to medication and ICBT, CBT was perceived as the most credible treatment for health anxiety. The highest preference ranks were for CBT and medication. Regression analyses indicated that lower computer anxiety, past medication use, and lower ratings of negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability. Limitations: Health anxiety was not assessed with a diagnostic interview. Primary care patients were recruited through a Qualtrics panel. Patients did not have direct experience with treatment but learned about treatment options through vignettes. Conclusions: Medication and CBT are preferred over ICBT. If ICBT is to increase treatment access, methods of improving perceptions of this treatment option are needed. © 2017 Elsevier Ltd. All rights reserved.

1. Introduction Severe health anxiety is a chronic and debilitating psychological problem, characterized by the fear that one has or will acquire a serious illness (Warwick & Salkovskis, 2001). In an attempt to reduce anxiety that is evoked by illness-related triggers (e.g., experiencing certain bodily sensations; Warwick & Salkovskis, 1990), individuals with severe health anxiety frequently request € rgvinsson, 2001). Consemedical tests and procedures (Hart & Bjo quently, health anxiety is associated with increased health care use and, in turn, inflated societal costs (Fink, Ornbol, & Christensen,

* Corresponding author. 3737 Wascana Parkway, Regina, SK, S4S 0A2, Canada. E-mail address: [email protected] (H.D. Hadjistavropoulos). http://dx.doi.org/10.1016/j.jbtep.2017.02.002 0005-7916/© 2017 Elsevier Ltd. All rights reserved.

2010). Given that prevalence rates reach as high as 20% in medical outpatient clinics and the personal and societal costs associated with the condition (Tyrer et al., 2011), effective and accessible treatments for managing symptoms of severe health anxiety are required. Cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are promising approaches to treating severe health anxiety (for a review, see Taylor, Asmundson, & Coons, 2005). Nevertheless, barriers to service access are evident in clinical practice limiting the number of individuals who seek help for severe health anxiety. Long waiting periods, geographical constraints, stigma associated with treatment use, and high treatment costs have been identified as barriers to accessing psychological treatments (e.g., Sunderland & Findlay, 2013), and poor compliance and negative side effects have been acknowledged as limitations of

J.N. Soucy, H.D. Hadjistavropoulos / J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

pharmacological treatments (Taylor & Asmundson, 2004). Providing therapy over the Internet may address treatment barriers and provide clients who are uncertain about their need for psychological treatment a safe method for accessing services. One approach to delivering treatment online is Internetdelivered cognitive behaviour therapy (ICBT), which involves sharing CBT techniques used in face-to-face therapy through structured web-pages (Andersson, 2010). To date, the efficacy of ICBT for severe health anxiety has been demonstrated in several randomized-controlled trials (i.e., Hedman et al., 2011, 2014, 2016). For example, Hedman et al. (2011) found that participants who received 12 modules of ICBT, with minimal therapist contact (i.e., on average, 9 min per week via a secure online forum), reported substantial reductions in health anxiety relative to no treatment controls following completion of the program and at 6-month follow-up. Furthermore, Hedman et al. (2014) established that ICBT was significantly more efficacious than Internet-delivered behavioural stress management at post-treatment, with gains maintained at 6-month follow-up. These findings are comparable to results from randomized-controlled trials examining the efficacy of face-to-face CBT for severe health anxiety (e.g., Olatunji et al., 2014). Despite evidence suggesting that ICBT is an efficacious treatment for severe health anxiety, other factors may influence treatment uptake and adherence if ICBT were to be available on a wider scale. Diller, Brown, and Patros (2013) underscore the importance of investigating treatment preference among clients, as patients may not adhere to the protocols of interventions that are effective but regarded as unacceptable. In support of this assertion, research suggests that ICBT credibility is significantly associated with larger improvements in symptoms of health anxiety (Hedman, Andersson, Lekander, & Ljotsson, 2015). To date, one research team has investigated the acceptability of treatments for severe health anxiety among individuals seeking help for the problem. Walker, Vincent, Furer, Cox, and Kjernisted (1999) recruited 23 individuals with hypochondriasis who were interested in participating in a pharmacological or a psychological treatment study, with assignment to either treatment partly determined by participants’ preferences. Participants were first presented with descriptions of the protocols, including advantages and disadvantages, then asked to rate their acceptability and predicted effectiveness and to rank the treatments in order of preference. Relative to medication, CBT was rated as more acceptable (d ¼ 1.23) and was expected to be more effective in the short- (d ¼ 0.61) and long-term (d ¼ 1.13). Moreover, three-quarters of the sample selected CBT as the treatment of choice, with only 4% having a preference for medication. Findings reported by Walker et al. (1999) indicate that CBT is perceived as an acceptable and effective treatment for severe health anxiety in comparison to medication, at least among those who are seeking treatment for severe health anxiety. It remains unclear how individuals with severe health anxiety perceive ICBT and more importantly, if the service would be broadly accepted if offered in clinical practice. The only empirical evidence regarding the acceptability of ICBT for health anxiety comes from examination of attrition rates in the randomized-controlled trials for health anxiety. For example, Hedman et al. (2011) reported that out of the 40 participants assigned to the ICBT condition, 35% completed the 12-module treatment. Given that lack of time was cited as the main reason for withdrawing, it is possible that the participants perceived ICBT as acceptable, but could not commit due to time constraints. Examining the acceptability of ICBT is an important next step in understanding its potential as a treatment option for health anxiety. Also recognized as important for advancing uptake of mental

15

health services is identifying predictors of treatment acceptability, which may afford mental health workers the opportunity to identify groups that are likely to be more or less interested in ICBT (Hazlett-Stevens et al., 2002). In the ICBT literature, Schneider and Hadjistavropoulos (2014) found that initial interest in ICBT for chronic pain was associated with lower levels of computer-related anxiety as well as being female. Symptom severity has also been identified as an additional factor related to ICBT adherence and interest, although the direction of the relations has varied across studies. In some instances, higher symptom severity (Schneider & Hadjistavropoulos, 2014) and in other instances lower symptom severity (Gun, Titov, & Andrews, 2011) is related to adherence and interest in ICBT. Beyond these variables, it is quite possible that specific health-related cognitions and safety-seeking behaviours related to health anxiety could be predictive of interest in ICBT. From a theoretical perspective, for instance, it could be that elevated reassurance seeking or lack of trust in medical providers would be a predictor of interest in ICBT. In order to assist with implementation efforts, the present study was designed to understand whether ICBT is perceived as an acceptable treatment for severe health anxiety among primary care patients and to determine whether specific factors influence perceptions of ICBT. Given that individuals who are health anxious are known to seek treatment initially from physicians (Hart & € rgvinsson, 2001), the study focused on examining acceptBjo ability of and preference among primary care patients (defined as patients who reported a recent visit to a physician). The study included individuals with and without self-reported medical conditions as research shows that both groups can experience significant health anxiety (e.g., Janzen-Claude, Hadjistavropoulos, & Friesen, 2014). In particular, the aims were to answer the following three research questions: (1) is ICBT perceived by primary care patients as an acceptable and credible treatment for severe health anxiety relative to face-to-face CBT or medication?; (2) how do primary care patients rank ICBT for health anxiety as a treatment option compared to face-to-face CBT and medication?; and (3) what are variables that predict ratings of ICBT acceptability? Given that individuals with health anxiety have been found to seek reassurance online by comparing their perceived symptoms to those described on the Internet (Abramowitz, 2008), it was predicted that ICBT would be seen as an acceptable and credible method of receiving treatment comparable to face-to-face CBT and greater than medication. The predicted ratings of acceptability and credibility across the vignettes were hypothesized to correspond with rank ordering of the three treatments, with face-to-face CBT and ICBT emerging as the preferred interventions. Lastly, given the exploratory nature of the third research question, no directional hypotheses were made regarding predictors of ICBT acceptability with the exception that being female and reporting lower levels of computer anxiety were hypothesized to predict greater ICBT acceptability. 2. Method 2.1. Participants and recruitment Participants were recruited through Qualtrics Panel System (Qualtrics, Provo, UT). Qualtrics Panel System is an online survey platform that offers access to a plethora of individuals across North America with diverse backgrounds who are interested in contributing to research. It has become a popular recruitment method for researchers interested in assessing attitudes and perceptions (e.g., Bertrand, Sen, Otake, & Lee, 2014; Rolison, Hanoch, & Miron-Shatz, 2012; van Wagenen, Magnusson & Neiger, 2015), and is advantageous as it gives access to a broader more representative national

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J.N. Soucy, H.D. Hadjistavropoulos / J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

sample, than is typically available. With the Qualtrics Panel System, respondents are recruited through a number of methods, such as member referrals, targeted email lists, permission-based networks, and social media. In order to initially register with Qualtrics, respondents complete background questionnaires and agree to partake in online surveys for an incentive. Incentives are based on various factors (e.g., length of the online survey) and may include cash, airline miles, and gift cards. Using profile information provided by respondents, Qualtrics Panel Systems randomly selects potential participants who are likely to meet the respective eligibility criteria. These respondents are sent an invitation via email with the following information: (1) indication that the survey is for research purposes only; (2) expected length of survey; and (3) incentive for participation. In order to avoid biases, the email invitation does not specify details of the study. For the present study, Qualtrics Panel Systems recruited 116 patients who self-identified as being Canadian residents; at least 18 years of age; able to read, write, and communicate fluently in English; had access to a computer and the Internet; had visited a physician within the past 3 months concerning their health (and were thus considered primary care patients); and reported elevated levels of health anxiety as assessed on the 14-item Whiteley Index (WI; Pilowsky, 1967). The WI has good internal consistency among primary care patients with hypochondriasis (a ¼ 0.75; Conradt, Cavanagh, Franklin, & Rief, 2006) and is a widely disseminated measure of health anxiety severity (e.g., Barsky & Ahern, 2004; Greeven et al., 2007; Hedman et al., 2011). If participants met the above mentioned criteria and scored 5 on the WI, they were invited to participate in our study. The score on the WI was selected for inclusion as Hedman, Andersson, et al. (2015) and Hedman, Lekander, et al. (2015) found this to be the optimal cut-off score for detecting health anxiety. 2.2. Measures 2.2.1. Questionnaire battery The following measures were administered in an online survey format to individuals who were identified by Qualtrics as eligible for the study. Demographic information included sex, ethnicity, education level, living situation, relationship and employment status, province and location of residence, and education level. A number of self-report measures were administered to assess for health anxiety symptomology. In addition to the WI described above, the Short Health Anxiety Inventory (SHAI) was selected because it is based on the cognitive behavioural model of health anxiety (Salkovskis, Rimes, Warwick, & Clark, 2002). It has excellent internal consistency among medical samples (a ¼ 0.84e0.96) and has been shown to have good convergent and divergent validity (Alberts, Hadjistavropoulos, Jones, & Sharpe, 2013). To measure cognitions purported to underlie health anxiety, the Health Cognitions Questionnaire (HCQ; Hadjistavropoulos et al., 2012) was administered. Good predictive validity of health anxiety has been established using this instrument (Hadjistavropoulos et al., 2012). Further, the Questionnaire for assessing Safety Behaviours in Hypochondriasis/Health Anxiety (QSBH) was used to assess two types of safety behaviours, namely reassurance seeking and avoidance. The QSBH is a translation of a German version, which has been found to discriminate between individuals with hypochondriasis and individuals with anxiety disorders (Weck, Breham, & Schermelleh-Engel, 2013). A number of measures were administered to assess for healthrelated concepts. To assess somatic symptom burden, the Somatic Symptom Scale-8 (SSS-8; Gierk et al., 2014) was selected as the

instrument has been found to correlate positively with health care use (Gierk et al., 2015). To measure medical and psychological health care use associated with health anxiety over the past 6 months, the Medical Utilization Questionnaire (MUQ; Abramowitz, Deacon, & Valentiner, 2007) was administered. Lastly, to obtain a more comprehensive clinical and medical history, participants were asked questions about health-related issues and initial knowledge of ICBT and CBT as well as the use of prior and current psychological and pharmacological treatments. A number of self-report measures were administered to assess for comorbid psychopathology. To measure depression severity, the Patient Health Questionnaire-9 item (PHQ-9; Kroenke, Spitzer, & Williams, 2001) was selected as the questionnaire has strong psychometric properties (Kroenke et al., 2001). The Generalized Anx€we, iety Disorder 7-item (GAD-7; Spitzer, Kroenke, Williams, & Lo 2006) was used to assess for symptoms of anxiety. Although the GAD-7 was originally developed as a brief, diagnostic tool for generalized anxiety disorder (Spitzer et al., 2006), Kroenke, Spitzer, € we (2007) found that it was an effective Williams, Monahan, and Lo screening measure for other anxiety disorders. Given the nature of the study, the Computer Anxiety Rating Scale (CARS; Heinssen, Glass, & Knight, 1987) was also administered to measure anxiety in relation to computer use and technology. Heinssen et al. (1987) reported good convergent and divergent validity on the scale.

2.2.2. Measures of treatment acceptability, credibility, and expectancy The following measures were administered online following the presentation of each of the three treatment vignettes. The Treatment Acceptability and Adherence Scale (TAAS; Milosevic, Levy, Alcolado, & Radomsky, 2015) is a self-report scale of treatment acceptability. For a given treatment protocol, participants rate 8 items on a 0 (“Strongly disagree”) to 7 (“Strongly agree”) scale, with higher summed scores reflecting greater perceived acceptability. There are no interpretative guidelines for this scale, and therefore, a priori we considered a score above 28 out of 56 to represent moderate perceptions of treatment acceptability. Good internal consistency has been demonstrated in a clinically anxious sample (a ¼ 0.88; Milosevic & Radomsky, 2013). Two of the items contained statements that compared the treatment under investigation to other treatments (e.g., medication). Given that there were multiple treatments under investigation in the current study, these two items were not included. Despite these alterations, good internal consistency for scores on the revised 8-item TAAS were obtained in the current study (a ¼ 0.87- a ¼ 0.88). The Credibility and Expectations Questionnaire (CEQ; Devilly & Borkovec, 2000) is a 6-item self-report questionnaire that measures treatment credibility (e.g., believable, logical) and expectancy (e.g., likelihood of improvement). Items are rated either on a 1 (“Not at all”) to 9 (“Very much”) scale or 0e100% scale. Factor analysis conducted by Devilly and Borkovec (2000) supports the two-factor model of the CEQ. The instrument has previously been used in the ICBT research (e.g., Titov et al., 2010) and demonstrated good internal consistency on the credibility (a ¼ 0.90e0.94) and expectancy (a ¼ 0.81e0.93) subscales in the current study.

2.2.3. Measure of treatment preference After reading the vignettes, participants were asked to rank the three treatment options based on their preference for receiving the intervention for health anxiety. In an attempt to minimize order effects, the presentation of the three vignettes was randomized in Qualtrics across participants.

J.N. Soucy, H.D. Hadjistavropoulos / J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

17

2.3. Material

2.6. Power calculations

2.3.1. Study rationale Participants were informed of the aim of the study and were instructed to read the three treatment descriptions and then complete questionnaires that followed.

Power calculation was conducted to ensure we would have power for the most complex statistical analysis described above, namely multiple regression. Using G*Power 3 (Faul, Erdfelder, Lang, & Buchner, 2007), we identified that we required a sample of 114 participants for the multiple regression analysis, with 9 predictors, assuming a medium effect size (f2 ¼ 0.15) and a ¼ 0.05, and a power level of 0.80.

2.3.2. Treatment vignettes Vignettes describing CBT, ICBT, and medication were created. Following past research by Walker et al. (1999), the vignettes included a description of the protocol as well as advantages and disadvantages of each treatment. Prior to data collection, psychologists and psychiatrists (N ¼ 8) who were familiar with pharmacological and psychological treatments for severe health anxiety reviewed the vignettes to ensure accuracy of information and consistency across the descriptions and then provided feedback. Alterations to the content and structure of the vignettes were made based on this feedback. 2.4. Procedure Potential participants were sent an email invitation from Qualtrics Panel System that contained the link to the three-part online survey. In the first part of the survey, consent and basic eligibility questions were asked. When assessed as ineligible, the survey was discontinued and resources (e.g., online self-help material) were provided. Participants who met the inclusion criteria were directed to the second part of the survey, in which the questionnaires described above were administered (see section 2.2.1). In the third part of the survey, the study rationale was provided then the three treatment vignettes were presented in counterbalanced order. Following the presentation of each vignette, participants were prompted to complete the TAAS and the CEQ. Lastly, the Treatment Preference Form was administered. Participants were compensated $1.00 through Qualtrics Panel System. The mean duration of time to complete the survey was 34.28 min (SD ¼ 31.85). 2.5. Statistical analyses Descriptive statistics were examined in order to understand the demographic, clinical, and medical characteristics of the sample. Multiple regression analyses were used to examine predictors of participants' ICBT acceptability scores. A series of one-way repeated measures analyses of variance were conducted to explore if differences emerged between participants' perceptions of treatments for health anxiety. Friedman's nonparametric statistical test was conducted in order to determine whether the three vignettes were ranked differently in preference, with a thematic content analysis employed in order to follow-up on participants' preference rankings. Participants' responses to the open-ended question (“please provide a brief explanation for your ranking”) were coded following the protocol outlined by Braun and Clarke (2006). First, a list of topics and common responses was generated after reading the data. Next, codes were derived by systematically re-reading the data for patterns. Once the data was entirely coded, the third phase focused on generating themes. This was accomplished by collating codes into broader, meaningful categories. Fourth, the themes were refined by deleting or collapsing themes into broader categories. Lastly, definitions and names for themes were created. The primary rater coded all participant responses, and a secondary rater coded approximately 10% of the data (i.e., 12 participant responses) in order to establish reliability. Interrater reliability was checked by calculating Cohen's kappa.

3. Results 3.1. Sample characteristics Approximately three-quarters of the sample reported being diagnosed with a medical condition, with the most commonly endorsed conditions including asthma (21.60%), rheumatoid arthritis (10.30%), type II diabetes (10.30%), and Crohn's disease (4.30%). Conversely, only a third of the sample reported a suspected medical condition that had yet to be diagnosed. A number of suspected medical conditions were reported, including chronic pain, ulcers, ovarian cancer, kidney disease, lupus, hypothyroidism, and autoimmune disease. Participants indicated a mean duration of 1.56 months (SD ¼ 0.78) since their last contact with a physician or specialist regarding health concerns. Table 1 provides a comprehensive overview of the sample characteristics. 3.2. Data screening Prior to conducting the statistical analyses, individual values entered into the database were checked to ensure accuracy of data input. Furthermore, reversed scoring and summed scores were carefully reviewed to ensure no calculations errors were made. The data set was then inspected for missing values by visually inspecting the data set as well as checking the sample size for each variable of interest. Outliers were determined by converting total and subscale scores on all variables of interest to z-scores. The standardized values were then compared to a recommended criterion for detecting statistically significant outliers (i.e., ±3.29, p < 0.001; Tabachnick & Fidell, 2001). This process identified two outliers, which were subsequently corrected by changing the extreme values to one unit smaller than the following largest score in the distribution that was not deemed an outlying score (Tabachnick & Fidell, 2001). This process was found to correct for statistically significant outliers. Data were then screened for normality. A number of scales (i.e., QSBH, HCQ, and CEQ) had nonnormal distributions, but were not transformed given that 1) this would reduce our ability to interpret the scores (Tabachnick & Fidell, 2001); 2) common data transformations did not correct for skewness or resulted in kurtosis; and 3). according to Field (2013), the F-statistic of the ANOVA can be robust to violations of normality when group sizes are the same. Moreover, a number of steps were taken in order to check the assumptions of multiple regression analysis. First, a correlation matrix was derived for all of the predictor variables in order to test for multicollinearity. There appeared to be no multicollinearity in the data as there were no substantial correlations (i.e., r > 0.90) found among the predictor variables and there were acceptable scores found on variance and inflation factors (Field, 2013). The assumption of independent error was also met, as Durbin-Watson statistic was above 1 but below 3, suggesting that the residuals in the model are independent (Field, 2013). Lastly, the graphical representations demonstrated the expected pattern of an evenly distributed array of dots around zero, indicating that the assumptions of linearity and homoscedasticity were met (Field, 2013).

Table 1 Descriptive statistics for sample characteristics. N Age Sex Female Male Other Province of residence Western Canada Eastern Canada Location of residence Large city (>200,000) Medium city (40,000e199,000) Small city (10,000e39,999) Rural (<9999) Living situation Live alone Live with partner Live with family Live with friend(s) Other Relationship status Single Dating or married Separated or divorced Other Ethnicity Caucasian Asian Hispanic Other Employment status Employed full-time Retired Long-term disability Student Other Education Less than high school High school diploma College certificate or some university University degree University professional or graduate degree Current therapy or counselling Yes No Past therapy or counselling Yes No Current medication Yes No Past medication Yes No Measures of health anxiety WI SHAI Measure of health cognitions HCQ, Difficulty coping subscale HCQ, Likelihood of illness subscale HCQ, Awfulness of illness subscale HCQ, Medical service inadequacy subscale Measure of health anxiety behaviours QSBH, Checking subscale QSBH, Avoidance subscale Measure of health SSS-8 Measures of psychopathology PHQ-9 GAD-7 CARS Therapy background CBT familiarity ICBT familiarity

Percentage

81 34 1

69.8 29.3 0.9

49 67

42.2 57.8

57 29 8 22

49.1 25.0 6.9 19.0

19 46 38 7 6

16.4 39.7 32.8 6.0 5.2

33 66 12 5

28.4 57.0 10.3 4.3

100 8 2 6

86.2 6.9 1.7 5.1

70 13 14 3 9

60.3 11.2 12.1 2.6 7.8

2 25 55 21 13

1.7 21.6 47.4 18.1 11.2

24 92

20.7 79.3

62 54

53.4 46.6

41 75

35.3 64.7

72 44

62.1 37.9

Score range

M

SD

18e74

41.34

14.92

0e14 0e42

8.35 16.14

2.39 7.64

8e40 4e20 4e20 4e20

23.28 13.47 15.20 11.53

5.96 3.70 3.04 3.40

0e32 0e32

13.97 8.54

6.18 8.03

0e32

13.60

6.48

0e27 0e21 19e95

10.59 9.24 43.77

6.79 6.19 13.15

1e5 1e5

2.82 1.99

1.32 1.20

Note. Values are rounded up two decimal places; Eastern Canada ¼ Ontario, Quebec, New Brunswick, Nova Scotia, and Newfoundland; WI ¼ Whiteley Index; SHAI ¼ Short Health Anxiety Inventory; HCQ ¼ Health Cognitions Questionnaire; QSBH ¼ Questionnaire for assessing Safety Behaviours in Hypochondriasis/Health Anxiety; SSSe8 ¼ Somatic Symptom Scalee8 item; PHQ-9 ¼ Patient Health Questionnairee9 item; GAD-7 ¼ Generalized Anxiety Disordere7 item; CARS ¼ Computer Anxiety Rating Scale; CBT ¼ Cognitive behaviour therapy; ICBT ¼ Internet-delivered cognitive behaviour therapy.

J.N. Soucy, H.D. Hadjistavropoulos / J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

3.3. Hypothesis testing 3.3.1. Treatment acceptability and credibility There was no statistically significant effect of group on treatment acceptability, F (1.56, 179.17) ¼ 2.39, p > 0.05, with all three treatments rated as equally acceptable for treating health anxiety. Given the highest possible TAAS score is 56, the treatments were perceived as moderately acceptable interventions for health anxiety as participants’ acceptability scores averaged 37.46 (SD ¼ 9.32) for ICBT, 36.78 (SD ¼ 9.39) for CBT, and 35.52 (SD ¼ 10.36) for medication. There was a statistically significant effect of group on treatment credibility ratings, F (1.69, 193.84) ¼ 6.22, p < 0.05. Post-hoc tests, using a Bonferroni correction, revealed that CBT was perceived as significantly more credible than ICBT (p ¼ 0.002) and medication (p ¼ 0.010). In contrast, there was no statistically significant difference between credibility scores for ICBT and medication (p ¼ 1.00). Participants’ credibility scores averaged 17.74 (SD ¼ 5.59) for ICBT and 17.35 (SD ¼ 6.50) for medication in comparison to 19.10 (SD ¼ 5.05) for CBT, indicating that these treatments were perceived to be relatively credible interventions for health anxiety given that the highest possible CEQ credibility subscale score is 27.

3.3.2. Treatment preference As illustrated in Fig. 1, there was a statistically significant difference in the way the treatments were ranked in preference, c2(2) ¼ 18.67, p < 0.001. Follow-up analyses using Wilcoxon signedrank tests were subsequently conducted with a Bonferroni correction set to 0.016 (Field, 2013). The results indicated that CBT and medication were preferred over ICBT (p < 0.016) and there was no statistically significant difference in how participants ranked CBT versus medication for severe health anxiety (p > 0.016). In order to further explore primary care patients’ perceptions of treatments for health anxiety, a thematic content analysis was conducted. Importantly, strong agreement (Kappa ¼ 0.99) was found on the 10% of responses that were coded by both raters. Participants identified a number of reasons for their preference rankings. A comprehensive overview of the reasons provided for low or high preference for each treatment is given in Table 2. While some comments were restated from the vignettes, a number of

* 3

*

Mean rank

2.5 2 1.5 1 0.5 0 Medication

CBT

ICBT

Group Fig. 1. Mean preference rank for the three treatment descriptions. Graph is to scale, with lower mean rank numbers representing greater treatment preference. CBT ¼ Cognitive behaviour therapy; ICBT ¼ Internet-delivered cognitive behaviour therapy. *p < 0.016.

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unique reasons were discussed. For example, participants reported that lack of familiarity and limited current availability were reasons that ICBT was ranked low in preference. Conversely, for other participants, ICBT was rated as a preferred treatment as the service was perceived as reducing anxiety about social interactions with a therapist. 3.3.3. Predictors of ICBT acceptability As depicted in Table 3, two models emerged as significant predictors of ICBT acceptability ratings. The first model identified that lower computer anxiety significantly predicted greater ICBT acceptability, F(1, 113) ¼ 10.98, p < 0.001, R2 ¼ 0.089. In the second model, lower computer anxiety and lower ratings of negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability, F(2, 112) ¼ 8.24, p < 0.001, R2 ¼ 0.128. An exploratory multiple regression was also conducted in order to examine whether additional background variables that had not been hypothesized a priori predicted ICBT acceptability. The variables examined were diagnosed medical condition (condition ¼ 1; no condition ¼ 2), initial knowledge of ICBT, history of medication and therapy use (past use ¼ 1; no past use ¼ 2), and current medication and therapy use (current use ¼ 1; no current use ¼ 2). As exhibited in Table 4, past medication use significantly predicted greater ICBT acceptability, F(1, 114) ¼ 7.54, p < 0.05, R2 ¼ 0.062. 4. Discussion Despite evidence suggesting that ICBT for health anxiety has comparable effects to CBT (Hedman et al., 2011; Olatunji et al., 2014), other factors may influence treatment uptake in clinical practice. In particular, treatment preference has been acknowledged as important given that therapeutic protocols that are efficacious, but regarded as unacceptable by clients, may not be adhered to and, therefore, may not be effective when implemented (Diller et al., 2013). Prior to the present study, it was unknown if ICBT for health anxiety would be broadly accepted if offered to primary care patients with health anxiety especially when compared to other established treatments. The goals of this investigation were to examine how primary care patients perceive ICBT relative to other interventions for health anxiety (i.e., CBT, medication) and to determine whether perceptions of ICBT are influenced by demographic and clinical variables. In order to assess primary care patients’ perceptions of treatments for health anxiety, patients were first presented with treatment vignettes and then completed measures of treatment acceptability and credibility. Results indicated that medication, CBT, and ICBT were all perceived to be moderately acceptable and relatively credible interventions for health anxiety. Contrary to our first hypothesis, no group differences were observed for acceptability ratings, suggesting that primary care patients perceived all treatments for health anxiety to be moderately acceptable. The finding that treatments were rated comparably does not support previous research conducted by Walker et al. (1999), who found that relative to medication, CBT was rated by a small sample of individuals with a primary diagnosis of hypochondriasis as considerably more acceptable (i.e., averaged 3.1 for medication and 7.0 for CBT on an 8-point scale). Also contrary to hypothesis, ICBT was rated as slightly less credible than CBT but similar to medication; however, overall differences in credibility ratings were quite minor. These credibility ratings were comparable to scores obtained in a recent study, which examined perceptions of ICBT before and after watching an educational video about ICBT (Soucy, Owens, Hadjistavropoulos, Dirkse, & Dear, 2016). Similarly, our second hypothesis was partially supported. CBT

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J.N. Soucy, H.D. Hadjistavropoulos / J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

Table 2 Thematic content analysis for participants’ responses regarding treatment preference rank. Treatment modality

Reasons for higher preference

Reasons for lower preference

Medication

-

Effectiveness Corrects for chemical imbalances Familiarity Good first step* See benefits relatively quickly

CBT

-

Addresses the problem Accountability* Greater level of support Learn coping skills Develop confidence when working with a therapist* Good first step* Familiarity* Comfort in using the Internet* Credibility Anonymity Addresses the problem Learn coping skills Convenience Reduces anxiety about social interactions with a therapist*

-

Do not like taking pills Negative side effects Temporary fix Do not believe in medication* Not effective for everyone* Difficulties weaning off* Cannot mix with other medications* Possibility of supplies running low* Lack of confidence in therapist* Interactions with a therapist could heighten social anxiety* Difficulties finding a therapist that fits needs Requires taking time off/leaving house Stigma*

-

Lack of confidence in therapist* Difficulties adhering due to less accountability* No face-to-face contact/less support* Not widely available* Lack of familiarity* Requires use of the Internet

ICBT

Note. *Denotes reasons that were unique and not discussed in the respective vignettes.

Table 3 Regression analyses showing demographic and clinical predictors of ICBT acceptability.

Model 1 Model 2

Predictors

Beta

SE

Constant CARS Constant CARS HCQ, Difficulty coping

46.81 -0.21 53.32 -0.19 -0.32

2.94 0.06 4.08 0.06 0.14

b -0.30*** -0.27** -0.20*

Note. Values are rounded up two decimal places; SE ¼ Standard error; ICBT ¼ Internet-delivered cognitive behaviour therapy; CARS ¼ Computer Anxiety Rating Scale; HCQ ¼ Health Cognitions Questionnaire. R2 ¼ 0.089 for Model 1, DR2 ¼ 0.040 for Model 2 (p < 0.05). *p < 0.05, **p < 0.01, and ***p < 0.001.

Table 4 Regression analyses showing medical predictors of ICBT acceptability. Predictors

Beta

SE

b

Constant Past medication use (past use ¼ 1; no past use ¼ 2)

44.03 4.76

2.54 1.74

-0.25*

Note. Values are rounded up two decimal places; SE ¼ Standard error; ICBT ¼ Internet-delivered cognitive behaviour therapy. R2 ¼ 0.062 (p < 0.05). *p < 0.05.

was assigned a high preference rank; however, both CBT and medication were ranked significantly higher than ICBT. The research diverges from that of Walker et al. (1999), who demonstrated that patients have a high preference for CBT over medication. The differences between the studies in preference ranking as well as acceptability ratings may be a function of the sample, as participants in the current study were primary care patients whereas participants in the Walker et al. (1999) study were individuals seeking treatment for severe health anxiety. One potential explanation is that primary care patients may perceive all treatments for health anxiety as less acceptable because these individuals may not have identified health anxiety as being a problem that requires treatment and are instead seeking biological rather psychological explanations for symptoms (Abramowitz et al., 2007). Results from the current study contribute to the literature by demonstrating that ICBT yielded generally favourable perceptions

among primary care patients. Content analysis of qualitative comments, indicated that participants viewed ICBT as having some benefits, including convenience, acceptability, anonymity, and effectiveness. Nevertheless, participants in the current study ranked CBT and medication as the preferred treatments for health anxiety relative to ICBT. Lack of accountability and familiarity, less therapeutic support, and limited ICBT availability in Canada were identified through qualitative feedback as disadvantages. Interestingly, recent research indicates that the efficacy of ICBT for health anxiety is preserved when clients are provided no therapeutic contact (Hedman et al., 2016). Despite lack of therapeutic contact being a concern that may influence patients’ perceptions of ICBT, it appears to not affect the actual outcome of treatment. Given that previous research indicates that positive expectations are associated with program adherence (e.g., Cavanagh et al., 2009), establishing different methods for increasing client familiarity with ICBT may be warranted. Educating clients about ICBT may be one approach. Although participants received written information about ICBT in the current study, it is possible that the sample required more education in order to make an informed decision about treatment choice for health anxiety. Soucy et al. (2016) found that presenting clients with an educational video about the availability of a local ICBT service significantly increased expectations of the treatment, suggesting that video education may be a valuable method for promoting ICBT. Alternatively, given the current finding that medication, CBT, and ICBT were all rated as moderately acceptable, it may be that primary care patients require greater educational information generally about the nature and consequences of health anxiety (e.g., the effect of hypervigilance on the maintenance of symptoms). A primary care sample may inherently perceive their symptoms to have an organic cause and, therefore, deem any treatment for a psychological problem as having lower acceptability. As expected and consistent with previous research (Schneider & Hadjistavropoulos, 2014), clients who reported less anxiety about using computers were more likely to report that ICBT is an acceptable method of service delivery. This evidence, coupled with data that Canadian adults are increasingly using the Internet (Statistics Canada, 2013), supports the efforts for implementing ICBT as a treatment for health anxiety. Given that the frequency of

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Internet use has increased over the years, it can be expected that familiarity with computer and Internet use will follow a similar trajectory. As such, more adults are likely to feel comfortable using the Internet and, in turn, may perceive ICBT to be a more acceptable treatment. Of note, research indicates that computer skills do not actually predict ICBT outcome for health anxiety (Hedman et al., 2013), which suggests that this factor may be more important when clients are considering ICBT rather than actually participating in ICBT. In terms of other predictors, analyses demonstrated that less negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability. It appears that individuals who may interpret their illness as easier to manage perceive a treatment that is accessed over the Internet as more acceptable. Finally, we found that those who have attempted but are not currently using medication may perceive Internet therapy as a more acceptable treatment. This evidence provides insight into establishing an understanding of which clients may be better suited to participate in ICBT for health anxiety. 4.1. Limitations The findings should be considered in light of limitations of the current study. It should be acknowledged that the three treatment vignettes used as study materials may have had subtle, unintended differences that could have influenced participants’ ratings. That said, a number of steps were taken in the current study to limit the likelihood of discrepancies emerging between the treatment vignettes (e.g., match the vignettes in reading level, style, and content). Moreover, due to time and resource limitations, no diagnostic assessment was conducted in order to validate the clinical characteristics of the sample. Rather a cut-off score on a psychometrically sound measure (i.e., WI) was used to detect individuals with elevated levels of health anxiety, with an additional measure of health anxiety symptomology (i.e., SHAI) used to validate scores obtained on the WI. Although using the Qualtrics Panel Systems to recruit participants for the current study may be subject to biases, many reputable journals (e.g., Bertrand et al., 2014; Cheng, 2014; Rolison et al., 2012) have published research using this recruitment method that would not be possible within the scope of local recruitment. Based on the available research, the current sample was also deemed to be representative of the population under investigation (i.e., individuals with health anxiety in the context of primary care) as evident by clinical outcomes assessing health anxiety severity (Bailer et al., 2015) and the reported frequency of health care use (Barsky, Ettner, Horsky, & Bates, 2001, 2005). Nevertheless, it should be acknowledged that the current study findings should be replicated within different samples of health anxious adults. 4.2. Future directions In the future, it would be desirable to go beyond the present findings and examine variables that predict actual engagement in ICBT. In the current study, past medication use, health cognitions, and computer anxiety predicted ICBT acceptability ratings but it is important to investigate if these variables will also predict actual use of ICBT. In order to provide further insight into the likely adoption rate of ICBT for health anxiety, it would also be important to assess professionals’ attitudes towards ICBT for health anxiety as healthcare professionals assist patients in becoming familiar with community resources. Given that lack of familiarity was reported as a concern with ICBT, it is possible that the service would be preferred to other treatments if clients had more knowledge of ICBT. Using a video may be an effective and engaging method to educate potential clients about ICBT for health anxiety (Soucy et al.,

21

2016). It would then be possible to examine if improving familiarity with ICBT among individuals with health anxiety impacts treatment preference. Alternatively, it is plausible that perceptions of all treatments for health anxiety would improve if primary care patients were first provided with more education about the nature and consequences of health anxiety. Presenting primary care patients with this information may assist in determining whether the provision of psychoeducation about health anxiety improves treatment perceptions among this specific sample. These proposed investigations may provide critical evidence to further support the implementation efforts of ICBT for health anxiety. 5. Conclusion The current results indicated that while ICBT is perceived by primary care patients as a moderately acceptable and credible treatment option for health anxiety, CBT and medication are ultimately preferred. Despite this, the finding that ICBT is perceived as acceptable and credible as other established treatments for health anxiety is promising given that there is a large gap in patient familiarity with ICBT relative to CBT and medication. The advantages of ICBT in improving service access and reducing stigma (Andersson, 2010) coupled with the generally favourable perceptions observed in the current study provide evidence to suggest that ICBT would likely be considered a desirable treatment option by a number of potential users. The findings serve to identify patient groups (e.g., individuals with lower self-reported computer anxiety) that would be most interested in ICBT and also identify concerns about ICBT (e.g., lack of therapeutic contact) that could be addressed through psychoeducation to improve interest in ICBT. Acknowledgement This project was supported by grants awarded to the second author from the Canadian Institutes of Health Research (Grant 293379) and the Saskatchewan Health Research Foundation (Grant 2778). We wish to thank Cassandra Chang for her help with recruitment. Appendix A. Treatment vignettes A.1. Medicine Certain medicines have been found to reduce symptoms of health anxiety. These medicines are called anti-depressants. There are a number of different anti-depressants that can be taken. Common anti-depressant medicines include Prozac, Zoloft, Paxil, Citalopram, Cymbalta, and Effexor. Medicines for health anxiety focus on balancing chemicals in the brain that affect emotions, like anxiety. Patients with health anxiety may have thoughts that certain illnesses are severe or that they would not be able to cope if they developed an illness. In terms of behaviours, patients may avoid situations (e.g., hospitals) that increase their fear of obtaining an illness. Patients may also repeatedly seek out reassurance from physicians, read about symptoms on the Internet or check their bodies for new symptoms. The goal of medicine is to increase certain chemical levels in the brain. Balancing out these chemicals in the brain can help reduce anxiety. Medicine is often prescribed in a family doctor or psychiatrist's office. Medicine is obtained from a pharmacy. Pharmacists are able to provide patients with education on how the medicines work as well as on common side effects. In order to give you a sense of how medicine is used to treat health anxiety, we would like to provide you with information about a study on medicine for health anxiety. Doctor Anja Greeven and her colleagues had patients with health anxiety take Paxil for 16 weeks.

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In the first few weeks of treatment, patients started taking a small daily dose (i.e., 10 mg) of Paxil. This was gradually increased each week to a maximum daily dose of 60 mg. The psychiatrist would decrease the dose of Paxil if patients had difficulty with side effects. Common side effects included feeling tired and experiencing reduced sexual functioning, problems sleeping, sweating, and headaches. Over the course of 16 weeks, patients saw the psychiatrist 12 times, with each meeting lasting approximately 20 min. During these meetings the psychiatrist would review how the medicine was working and note down any side effects. The psychiatrist would adjust the dose of the medicine if the patient found the side-effects upsetting or if health anxiety did not decrease. At the end of the study, patients reported significant reductions in symptoms of health anxiety, depression, and general anxiety. The reductions were greater than patients who were provided a placebo, which is a tablet that contains no active medicine. Advantages:  Medicine can be prescribed by a family doctor or psychiatrist.  Patients are used to seeing physicians for health anxiety.  Most communities have pharmacies or stores where patients can pick up and refill their medicine.  Taking medicine each day takes little time or energy on the part of the patient. Disadvantages:  Side effects can happen early on in treatment and last for a few weeks or longer.  Patients may feel that improvements are because of the medicine and not their own achievements.  Medicine is often continued for at least 12 months after the patient is feeling better.  It is possible that symptoms of health anxiety may reappear once medicine is stopped.

building up to more anxiety provoking situations. Patients were also encouraged to reduce reassurance seeking and symptom checking as these increase rather than decrease health anxiety. Treatment finished with patients developing a plan for how they would cope if symptoms of health anxiety reappeared. Over the course of the program, patients could email their therapist questions and expect a response within a day. Patients were assigned homework exercises at the end of each lesson. Amount of time needed for homework varied for each client, but often took time each day. Patients reported significant reductions in symptoms of health anxiety, depression, and general anxiety at the end of the study in comparison to patients who did not receive the program. Advantages:  Patients learn strategies that reduce symptoms of health anxiety and effects remain if patients continue to use the strategies.  Patients can access the program any time of day in the comfort of their own home.  Many patients find this treatment to be more private.  The therapist does not need to be in the same community as the patient. Disadvantages:  Patients must be able to read at a certain level, be comfortable with writing, and have access to a computer.  It is more difficult for a therapist to adapt the program to the needs of the patient.  Internet-delivered cognitive behaviour therapy requires time and effort in order to reduce health anxiety.  Patients may experience increased anxiety initially when beginning to practice some skills.

A.3. Cognitive behaviour therapy A.2. Therapist-assisted internet-delivered cognitive behaviour therapy Internet-delivered cognitive behaviour therapy is a type of therapy that has been shown to reduce symptoms of health anxiety. This therapy focuses on helping patients understand how certain thoughts and actions affect emotions, like anxiety. Patients with health anxiety may have thoughts that certain illnesses are severe or that they would not be able to cope if they developed an illness. In terms of behaviours, patients may avoid situations (e.g., hospitals) that increase their fear of obtaining an illness. Patients may also repeatedly seek out reassurance from physicians, read about symptoms on the Internet or check their bodies for new symptoms. The goal of therapy is to change thoughts and behaviours in ways that will help reduce anxiety. The program presents written information along with visual images over the Internet in the form of weekly lessons. Often a therapist checks in with patients by phone or email on a weekly basis using a website with high security. In order to give you a sense of Internet-delivered cognitive behaviour therapy, we would like to provide you with information about a study on this therapy. Doctor Erik Hedman and his colleagues had patients access 12 lessons over 12 weeks. In the first two lessons of the program, patients were provided facts about health anxiety and on common health anxious thoughts and behaviours. Lessons 3 to 11 presented information on different skills to cope with health anxiety. Patients learned how to identify and change negative thoughts and worries about illness that were untrue or unhelpful. Patients also created a list of situations they feared and were then asked to safely and gradually approach these situations, beginning with something that was only slightly anxiety-provoking and

Cognitive behaviour therapy is a type of therapy that has been shown to reduce symptoms of health anxiety. This therapy focuses on helping patients understand how certain thoughts and actions affect emotions, like anxiety. Patients with health anxiety may have thoughts that certain illnesses are severe or that they would not be able to cope if they developed an illness. In terms of behaviours, patients may avoid situations (e.g., hospitals) that increase their fear of obtaining an illness. Patients may also repeatedly seek out reassurance from physicians, read about symptoms on the Internet or check their bodies for new symptoms. The goal of therapy is to change thoughts and behaviours in ways that will help reduce anxiety. Therapy is often conducted in a therapist's office. In order to give you a sense of cognitive behaviour therapy, we would like to provide you with information about a study on this therapy. Doctor Hilary Warwick and her colleagues had patients attend therapy sessions with a therapist on a weekly basis for up to 16 weeks. In the first few therapy sessions, patients were provided facts about health anxiety and on common health anxious thoughts and behaviours. In later sessions, the therapist helped the patient learn new ways to cope with health anxiety. The therapist helped the patient identify and change negative thoughts and worries about illness that were untrue or unhelpful. The patient and therapist also worked together to create a list of situations the patients feared. The patient then gradually and safely approached situations that were feared, beginning with something that was only slightly anxiety-provoking and building up to more anxiety-provoking situations. Patients were also encouraged to reduce reassurance seeking and symptom checking as these increase rather than decrease health anxiety. Treatment finished with patients developing a plan for how they would cope if symptoms of health

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anxiety reappeared. Skills were first practiced in therapy sessions with the therapist present. Patients were assigned homework exercises at the end of each session. These exercises included tracking symptoms of anxiety and practicing skills outside of the therapist's office. Amount of time needed for homework varied for each client, but often took time each day. Patients reported significant reductions in symptoms of health anxiety, depression, and general anxiety at the end of the study in comparison to patients who did not receive the treatment. Advantages:  Patients learn strategies that reduce symptoms of health anxiety and effects remain if patients continue to use the strategies.  The therapist is available in the session and can easily assess if patients fully understand information presented.  The therapist can easily adapt information to the needs of the patient.  The therapist is available in the session when the patient first practices new skills. Disadvantages:  Many communities in Canada do not have psychologists or other professionals who are trained to provide cognitive behaviour therapy.  Patients need to set aside time each week usually during day time hours to attend appointments.  Cognitive behaviour therapy requires time and effort in order to reduce health anxiety.  Patients may experience increased anxiety initially when beginning to practice some skills. References Abramowitz, J. S. (2008). New directions in health anxiety: Introduction to the special issue. Journal of Cognitive Psychotherapy: An International Quarterly, 22, 83e86. Abramowitz, J. S., Deacon, B. J., & Valentiner, D. P. (2007). The Short Health Anxiety Inventory: Psychometric properties and construct validity in a non-clinical sample. Cognitive Therapy and Research, 31, 871e883. http://dx.doi.org/ 10.1007/s10608-006-9058-1. Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., & Sharpe, D. S. (2013). The short health anxiety inventory: A systematic review and meta-analysis. Journal of Anxiety Disorders, 27, 68e78. http://dx.doi.org/10.1016/j.janxdis.2012.10.009. Andersson, G. (2010). The promise and pitfalls of the Internet for cognitive behavioral therapy. BMC Medicine, 8(82), 1e5. http://dx.doi.org/10.1186/17417015-8-82. Bailer, J., Kerstner, T., Witthoft, M., Diener, C., Mier, D., & Rist, F. (2015). Health anxiety and hypochondriasis in the light of DSM-5. Anxiety, Stress, & Coping, 1e21. http://dx.doi.org/10.1080/10615806.2015.1036243. Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: A randomized controlled trial. Journal of the American Medical Association, 291, 1464e1470. Barsky, A. J., Ettner, S. L., Horsky, J., & Bates, D. W. (2001). Resource utilization of patients with hypochondriacal health anxiety and somatization. Medical Care, 39, 705e715. Barsky, A. J., Orav, E. J., & Bates, D. W. (2005). Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archive of General Psychiatry, 62, 903e910. Bertrand, A. A., Sen, S., Otake, L. R., & Lee, G. K. (2014). Changing attitudes toward hand allotransplantation among North American and surgeon. Hand Surgery, 72, 56e60. http://dx.doi.org/10.1097/SAP.0000000000000147. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77e101. http://dx.doi.org/10.1191/ 1478088706qp063oa. Cavanagh, K., Shapiro, D. A., Van Den Berg, S., Swain, S., Barkham, M., & Proudfoot, J. (2009). The acceptability of computer-aided cognitive behavioural therapy: A pragmatic study. Cognitive Behaviour Therapy, 38, 235e246. http://dx.doi.org/ 10.1080/16506070802561256. Cheng, H. (2014). Asian American and European Americans' stigma levels in response to biological and social explanation of depression. Social Psychiatry and Psychiatric Epidemilogy, 3, 210e218. Conradt, M., Cavanagh, M., Franklin, J., & Rief, W. (2006). Dimensionality of the whiteley index: Assessment of hypochondriasis in an australian sample of primary care patients. Journal of Psychosomatic Research, 60, 137e143. http:// dx.doi.org/10.1016/j.jpsychores.2005.07.003.

23

Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/ expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, 73e86. Diller, J. W., Brown, R. M., & Patros, C. H. G. (2013). Revisiting Kazdin (1980): Contemporary treatment acceptability for problem behavior in children. International Journal of Psychology and Psychological Therapy, 13, 225e231. Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175e191. http://dx.doi.org/10.3758/ BF03193146. Field, A. (2013). Discovering statistics using IBM SPSS statistics (4th ed.). London: Sage. Fink, P., Ornbol, E., & Christensen, K. S. (2010). The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS ONE, 5, 1e12. http://dx.doi.org/10.1371/journal.pone.0009873. €hler, E., et al. Gierk, B., Kohlmann, S., Kroenke, K., Spangenberg, L., Zenger, M., Bra (2014). The somatic symptom Scalee8 (SSS-8): A brief measure of somatic symptom burden. Journal of American Medicine Association Internal Medicine, 174, 399e407. http://dx.doi.org/10.1001/jamainternmed.2013.12179. Gierk, B., Kohlmann, S., Toussaint, A., Wahl, I., Brünahl, C. I., Murray, A. M., et al. (2015). Assessing somatic symptom burden: A psychometric comparison of the patient health Questionnaired15 (PHQ-15) and the somatic symptom Scaled8 (SSS-8). Journal of Psychosomatic Research, 78, 352e355. http://dx.doi.org/ 10.1016/j.jpsychores.2014.11.006. Greeven, A., van Balkhom, A. J. L. M., Visser, S., van Rood, Y. R., van Dyck, R., Van der Does, A. J., … Spinhoven, P. (2007). Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: A randomized controlled trial. American Journal of Psychiatry, 164, 91e99. Gun, S. Y., Titov, N., & Andrews, G. (2011). Acceptability of Internet treatment of anxiety and depression. Australasian Psychiatry, 19, 259e264. http://dx.doi.org/ 10.3109/10398562.2011.562295. Hadjistavropoulos, H. D., Janzen, J. A., Kehler, M. D., Leclerc, J. A., Sharpe, D., & Bourgault- Fagnou, M. D. (2012). Core cognitions related to health anxiety in self-reported medical and non-medical samples. Journal of Behavioural Medicine, 35, 167e178. http://dx.doi.org/10.1007/s10865-011-9339-3. €rgvinsson, T. (2001). Health anxiety and hypochondriasis: Description Hart, J., & Bjo and treatment issues highlighted through a case illustration. Bulletin of the Menninger Clinic, 74, 122e140. Hazlett-Stevens, H., Craske, M. G., Roy-Byrne, P. P., Sherbourne, C. D., Stein, M. B., & Bystritsky, A. (2002). Predictors of willingness to consider medication and psychosocial treatment for panic disorder in primary care patients. General Hospital Psychiatry, 24, 316e321.  tsson, B., Rück, C., Asmundson, G. A., Hedman, E., Andersson, G., Andersson, E., Ljo et al. (2011). Internet-based cognitive-behavioural therapy for severe health anxiety: Randomised controlled trial. British Journal of Psychiatry, 198, 230e236. http://dx.doi.org/10.1192/bjp.bp.110.086843. Hedman, E., Andersson, E., Lekander, M., & Ljotsson, B. (2015). Predictors in Internet-delivered cognitive behavior therapy and behavioral stress management for severe health anxiety. Behaviour Research and Therapy, 64, 49e55. http://dx.doi.org/10.1016/j.brat.2014.11.009. Hedman, E., Axelsson, E., Andersson, E., Lekander, M., & Ljotsson, B. (2016). Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: Randomised controlled trial. British Journal of Psychiatry, 209, 407e413. http://dx.doi.org/ 10.1192/bjp.bp.116.181396. € rling, A., Ritzman, C., Ronnheden, M., El Alaoui, S., et al. Hedman, E., Axelsson, E., Go (2014). Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: Randomised controlled trial. British Journal of Psychiatry, 205, 307e314. http://dx.doi.org/ 10.1192/bjp.bp.113.140913. tsson, B., Lindefors, N., Rück, C., Andersson, G., et al. Hedman, E., Lekander, M., Ljo (2015). Optimal cut-off points on the health anxiety inventory, illness attitude scales and whiteley index to identify severe health anxiety. PloS ONE, 10, e0123412. http://dx.doi.org/10.1371/journal.pone.0123412. Hedman, E., Lindefors, N., Andersson, G., Andersson, E., Lekander, M., Ruck, C., et al. (2013). Predictors of outcome in internet-based cognitive behavior therapy for severe health anxiety. Behaviour Research and Therapy, 51, 711e717. http:// dx.doi.org/10.1016/j.brat.2013.07.009. Heinssen, R. K., Glass, C. R., & Knight, L. A. (1987). Assessing computer anxiety: Development and validation of the computer anxiety rating scale. Computers in Human Behavior, 3, 49e59. http://dx.doi.org/10.1016/0747-5632(87)90010-0. Janzen-Claude, J. A., Hadjistavropoulos, H. D., & Friesen, L. (2014). Exploration of health anxiety among individuals with diabetes: Prevalence and implications. Journal of Health Psychology, 19, 312e322. http://dx.doi.org/10.1177/ 1359105312470157. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606e613. €we, B. (2007). Anxiety Kroenke, K., Spitzer, R. L., Williams, J. W., Monahan, P. O., & Lo disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146, 317e325. Milosevic, I., Levy, H. C., Alcolado, G. M., & Radomsky, A. S. (2015). The treatment acceptability and adherence scale: Moving beyond treatment effectiveness. Cognitive Behaviour Therapy, 44, 456e469. http://dx.doi.org/10.1080/ 16506073.2015.1053407. Milosevic, I., & Radomsky, A. S. (2013). Incorporating the judicious use of safety

24

J.N. Soucy, H.D. Hadjistavropoulos / J. Behav. Ther. & Exp. Psychiat. 57 (2017) 14e24

behaviour into exposure-based treatments for anxiety disorders: A study of treatment acceptability. Journal of Cognitive Psychotherapy, 27, 155e174. http:// dx.doi.org/10.1891/0889-8391.27.2.155. Olatunji, B. O., Kauffman, B. Y., Meltzer, S., Davis, M. L., Smits, J. A. J., & Powers, M. B. (2014). Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-analysis of treatment outcome and moderators. Behaviour Research and Therapy, 58, 65e74. http://dx.doi.org/10.1016/j.brat.2014.05.002. Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal of Psychiatry, 113, 89e93. Rolison, J. J., Hanoch, Y., & Miron-Shatz, T. (2012). Smokers: At risk for prostate cancer but unlikely to screen. Addictive Behaviors, 37, 736e738. http:// dx.doi.org/10.1016/j.addbeh.2012.02.006. Salkovskis, P. M., Rimes, K. A., Warwick, H. M. C., & Clark, M. (2002). The Health Anxiety Inventory: Development validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32, 843e853. doi: 10.1017}S0033291702005822. Schneider, L. H., & Hadjistavropoulos, H. D. (2014). When in doubt, ask the audience: Potential users' perceptions of Internet-delivered cognitive behavioural therapy for chronic pain. Pain Research and Management, 19(4), 173e178. Soucy, J. N., Owens, V., Hadjistavropoulos, H. D., Dirkse, D. A., & Dear, B. F. (2016). Educating patients about Internet-delivered cognitive behaviour therapy: Perceptions among treatment seekers and non-treatment seekers before and after viewing an educational video. Internet Interventions, 6, 57e63. http://dx.doi.org/ 10.1016/j.invent.2016.09.003. €we, B. (2006). A brief measure for Spitzer, R. L., Kroenke, K., Williams, J. B., & Lo assessing generalized anxiety disorder. Archives of Internal Medicine, 166, 1092e1097. Statistics Canada. (2013). Canadian Internet use survey, Internet use, by age group and household income for Canada, provinces and census metropolitan areas (CMAs), occasional (percent). Retrieved June 14, 2016, fromhttp://www5.statcan.gc.ca/ cansim/pick-choisir?lang¼eng&p2¼33&id¼3580154. Sunderland, A., & Findlay, L. C. (2013). Perceived need for mental health care in Canada: Results from 2012 canadian community health surveyemental health (catalogue no. 82-003-X). Health Reports, 24(9), 3e9.

Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). Boston, MA: Allyn and Bacon. Taylor, S., & Asmundson, G. J. G. (2004). Treating health anxiety: A cognitivebehavioural approach. New York, NY: The Guilford Press. Taylor, S., Asmundson, G. J. G., & Coons, M. J. (2005). Current directions in the treatment of hypochondriasis. Journal of Cognitive Psychotherapy, 19, 291e310. http://dx.doi.org/10.1891/088983905780907478. Titov, N., Andrews, G., Schwencke, G., Robinson, E., Peters, L., & Spence, J. (2010). Randomized controlled trial of Internet cognitive behavioural treatment for social phobia with and without motivational enhancement strategies. The Australian and New Zealand Journal of Psychiatry, 44, 938e945. http://dx.doi.org/ 10.3109/00048674.2010.493859. Tyrer, P., Cooper, S., Crawford, M., Dupont, S., Green, J., Murphy, D., … Tyrer, H. (2011). Prevalence of health anxiety problems in medical clinics. Journal of Psychosomatic Research, 71, 392e394. http://dx.doi.org/10.1016/ j.jpsychores.2011.07.004. van Wagenen, S. A., Magnusson, B. M., & Neiger, B. L. (2015). Attitudes toward breastfeeding among an Internet panel of U.S. males aged 21e44. Maternal and Child Health Journal, 19, 2020e2028. http://dx.doi.org/10.1007/s10995-0151714-1. Walker, J., Vincent, N., Furer, P., Cox, B., & Kjernisted, K. (1999). Treatment preference in hypochondriasis. Journal of Behavior Therapy and Experimental Psychiatry, 30, 251e258. http://dx.doi.org/10.1016/S0005-7916(99)00027-0. Warwick, H. M. C., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research Therapy, 28, 105e117. http://dx.doi.org/10.1016/0005-7967(90)90023-C. Warwick, H. M. C., & Salkovskis, P. M. (2001). Cognitive-behavioral treatment of hypochondriasis. In V. Starcevic, & D. R. Lipsitt (Eds.), Hypochondriasis: Modern perspectives on an ancient malady (pp. 314e328). New York, NY: Oxford University Press. Weck, F., Breham, U., & Schermelleh-Engel, K. (2013). Entwicklung und validierung eines fragebogens zur erfassung von hypochondrischem sicherheitsverhalten. Zeitschrift für Klinische Psychologie und Psychotherapie, 41. http://dx.doi.org/ 10.1026/1616-3443/a000174.