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Imagining the future in health anxiety:the impact of rumination on thespecificity of illness-related memoryand future thinkingUrsula M. Sansom-Dalyab, Richard A. Bryanta, Richard J. Cohnbc &Claire E. Wakefieldbc

a School of Psychology, University of New South Wales (UNSW),Level 10 Matthews Building, Kensington, NSW 2052, Australiab Kids Cancer Centre, Sydney Children's Hospital, Level 1 SouthWing, High St, Randwick, NSW 2031, Australiac School of Women's and Children's Health, University of NewSouth Wales (UNSW), Kensington, NSW 2052, AustraliaAccepted author version posted online: 07 Jan 2014.Publishedonline: 05 Feb 2014.

To cite this article: Ursula M. Sansom-Daly, Richard A. Bryant, Richard J. Cohn & Claire E.Wakefield (2014) Imagining the future in health anxiety: the impact of rumination on the specificityof illness-related memory and future thinking, Anxiety, Stress, & Coping: An International Journal,27:5, 587-600, DOI: 10.1080/10615806.2014.880111

To link to this article: http://dx.doi.org/10.1080/10615806.2014.880111

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Imagining the future in health anxiety: the impact of rumination onthe specificity of illness-related memory and future thinking

Ursula M. Sansom-Dalya,b*, Richard A. Bryanta, Richard J. Cohnb,c andClaire E. Wakefieldb,c

aSchool of Psychology, University of New South Wales (UNSW), Level 10 Matthews Building,Kensington, NSW 2052, Australia; bKids Cancer Centre, Sydney Children’s Hospital, Level 1 South

Wing, High St, Randwick, NSW 2031, Australia; cSchool of Women’s and Children’s Health,University of New South Wales (UNSW), Kensington, NSW 2052, Australia

(Received 21 June 2013; accepted 23 December 2013)

Individuals with health anxiety experience catastrophic fears relating to future illness.However, little research has explored cognitive processes involved in how healthanxious individuals picture the future. Ruminative thinking has been shown to impedethe ability to recall specific autobiographical memories, which in turn is related tomaladaptive, categoric future thinking processes. This study examined the impact ofrumination on memory and future thinking among 60 undergraduate participants withvarying health anxiety (35% clinical-level health anxiety). Participants were rando-mized to experiential/ruminative self-focus conditions, then completed an Autobio-graphical Memory Test and Future Imaginings Task. Responses were coded forspecificity and the presence of illness concerns. Rumination led to more specificillness-concerned memories overall, yet at the same time led to more categoric illness-related future imaginings. Rumination and health anxiety together best predictedovergeneral illness-related future imaginings. Highly specific illness-related memoriesmay be maintained due to their personal salience. However, more overgeneral illness-related future imaginings may reflect cognitive avoidance in response to the threat offuture illness. This divergent pattern of results between memory and future imaginingsmay exacerbate health anxiety, and may also serve to maintain maladaptive responsesamong individuals with realistic medical concerns, such as individuals living withchronic illness.

Keywords: autobiographical memory; future thinking; health anxiety; hypochondriasis;rumination

Few stressors so easily provoke fear and heightened anxiety as the prospect of beingdiagnosed with a serious illness (Cameron, 2003). However, in some individuals,significant and functionally impairing anxious preoccupation concerning future illnesspersists, despite the absence of any real health threat. Recent estimates suggest thathypochondriasis1 is seen in approximately 5% of the general population, and up to 9% ofpatients at general medical practice clinics (Creed & Barsky, 2004; Gureje, Üstun, &Simon, 1997). In addition to the considerable personal distress experienced by individualswith health anxiety, the prevalence of health anxiety has significant implications forburden of health service use (Barsky, Ettner, Horsky, & Bates, 2001; Noyes et al., 1994).

*Corresponding author. Email: u.sansomdaly@gmail.com

Anxiety, Stress, & Coping, 2014Vol. 27, No. 5, 587–600, http://dx.doi.org/10.1080/10615806.2014.880111

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Despite this, relatively little research has examined the underlying pathological processesthat maintain health anxiety.

Dysfunctional health beliefs have been identified as a potential maintaining factor inhealth anxiety, among both physically well individuals with hypochondriasis (Fulton,Marcus, & Merkey, 2011), and among physically unwell individuals, such as cancerpatients showing significant fear of cancer recurrence (Simard, Savard, & Ivers, 2010).These beliefs concern the prevalence of illness (serious illnesses are very prevalent), themeaning of ambiguous symptoms (likely to indicate something catastrophic), the resultsof an illness not being diagnosed immediately (catastrophic and fatal), and the meaningof “health” (that one needs to be completely symptom-free) (Fulton et al., 2011).

However, rather than focus solely on the dysfunctional content of such thoughts (whatpeople think), recent evidence-based treatments for health anxiety have focused onchanging individuals’ response to such thought processes (how people think). Forexample, recent trials of mindfulness-based cognitive therapy (MBCT; McManus,Surawy, Muse, Vazquez-Montes, & Williams, 2012) have shown it to be effective inreducing levels of health anxiety by assisting individuals to consciously respond in anonjudgmental manner to such maladaptive health-related thoughts (Segal, Williams, &Teasdale, 2002). Although encouraging, approximately 50% of the individuals whoreceived this treatment still met clinical criteria for a diagnosis of hypochondriasis post-treatment (McManus et al., 2012). Given this proportion of treatment nonresponders,investigations into the underlying cognitive processes that drive and maintain healthanxiety are warranted, both to refine theoretical models and better understand factors thatmay moderate response to treatments such as MBCT. It is likely that other cognitiveprocesses – beyond dysfunctional health beliefs – influence these outcomes. Given theinherent future-oriented focus of anxiety disorders, one process that may be critical toexplore is how health anxious individuals picture the future.

Memory, future thinking, and psychological disorders

Evidence suggests that individuals with many psychological disorders have difficulty inretrieving specific autobiographical memories (Williams et al., 2007). Specific memoriesrelate to a discrete event that occurred at particular place and time (e.g., “My exam lastTuesday”). By contrast, categoric or “overgeneral” memories (OGM) are summaries of acategory of events (e.g., “All the exams I’ve failed”) and are associated with depression(Watkins & Teasdale, 2004), post-traumatic stress disorder (Sutherland & Bryant, 2007),and complicated grief (Maccallum & Bryant, 2010). Recent evidence further indicatesthat while these disorders are associated with pervasive OGM, distinct patterns ofspecificity are seen for memories closely tied to the subject of a person’s distress (e.g., amemory of a deceased loved one in complicated grief), such that these personally salient,distressing memories are actually recalled in a more specific manner (Golden, Dalgleish,& Mackintosh, 2007).

The memory and future thinking systems are hypothesized to be driven by similarunderlying neural and cognitive mechanisms (Schacter, Addis, & Buckner, 2007), and thecontent and specificity of memory and future imaginings appear to be linked (Maccallum& Bryant, 2011; Williams et al., 1996). Consequently, the process of drawing specificinformation from personal memories is thought to be critical to the processes of clearlyenvisioning future life events consistent with their goals (Conway & Pleydell-Pearce,

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2000; Williams et al., 1996) and effective future-oriented problem solving (D’Zurilla &Nezu, 1980).

Understanding future thinking processes is particularly relevant in health anxiety,given that the distressing, intrusive imagery most health anxious individuals experiencerelates to their fear of future illness (Muse, McManus, Hackmann, Williams, & Williams,2010). To date, OGM has not been consistently demonstrated among anxiety disorders(Williams et al., 2007). However, several mechanisms implicated in recent models ofhealth anxiety – ruminative thinking and “functional avoidance” (i.e., as emotionregulation) – have been proposed to be key determinants of the specificity of memory/future thinking (Williams, 2006). As in other disorders, these cognitive and emotionalavoidance mechanisms may serve to facilitate OGM and future imaginings. Understand-ing how memory/future thinking processes may play a role within health anxiety remainsa gap in the literature.

Rumination and future thinking

One factor that has been shown to increase OGM is ruminative thinking – a circular, self-focused thinking style often seen in depression (Nolen-Hoeksema, Morrow, &Fredrickson, 1993). Rumination consists of both verbal and visual content, and maycontain a set of intrusive, distressing memories embedded within it (Pearson, Brewin,Rhodes, & McCarron, 2008; Watkins, Moulds, & Mackintosh, 2005). The process ofrumination may therefore lead individuals to perseverate on distressing memories ina maladaptive, overgeneral manner. In turn, the continual activation of this categoryof memories is likely to maintain their activation and accessibility, increasing thelikelihood that they will be retrieved in future (Brewin, 2006; Conway & Pleydell-Pearce, 2000).

Experimental studies have also borne out the relationship between rumination andOGM. Among depressed/dysphoric individuals, a brief rumination induction has beenshown to maintain or increase OGM, while a brief distraction induction reduces it(Watkins, Teasdale, & Williams, 2000). Further, among individuals with major depression,actively engaging in ruminative (analytical) self-focused attention appears to leadparticipants to generate more OGM, while adopting a more experiential (nonanalytical)self-focus reduces this (Watkins & Teasdale, 2004). As yet, no experimental studieshave examined the impact of rumination for health anxious individuals, despitesuggestions that it may be a maintaining factor in the disorder (Marcus, Hughes, &Arnau, 2008).

High health anxiety has, however, been associated with a greater reported use ofruminative thinking in nonclinical samples (Marcus et al., 2008), while obsessiverumination about illness has been suggested as a core clinical feature of hypochondriasis(Fink et al., 2004). Verbal-based, worry-type processes have also been implicated incancer patients experiencing significant fear of cancer recurrence (Simard et al., 2010).Further, recent advances in clinical hypochondriasis treatments have involved MBCT, atreatment program that specifically targets the process of rumination (McManus et al.,2012). Thus, converging lines of evidence implicates ruminative thinking as onemaladaptive cognitive process that may play a role in perpetuating health anxious pastand future thinking.

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The present study

This study extended the empirical literature on health anxiety by examining the effects ofa rumination induction on both OGM and future episodic thinking among individualswith varying levels of health anxiety. Given the implicated role of rumination in healthanxiety, the aim of this study was to investigate the impact of ruminative thinking onmemory/future thinking processes among individuals displaying a range of vulnerabilityto current health concerns. An undergraduate sample was used as a nonclinical model ofhealth/illness concerns. The validity of this approach is supported by research recognizingthe dimensional nature of health anxiety (Ferguson, 2009). Experimental investigationsinto potential cognitive mechanisms may therefore have important implications – andapplications – to health- and illness-related concerns across the continuum of severity.

The following hypotheses were made:

(1) Rumination effects: In line with the literature linking rumination with over-general, evaluative modes of thinking, participants receiving a ruminationinduction would report more overgeneral memory and future thinking, comparedto other participants.

(2) Health anxiety effects: Higher health anxiety would be associated with generatingmore illness-related memories/future imaginings.

(3) Rumination and health anxiety effects: Among individuals with higher healthanxiety, rumination may potentiate their tendency to generate more overgeneralmemories and future imaginings, averaged across all memory/future imaginings’content.

(4) Rumination and health anxiety effects: In contrast to Hypothesis 3, we expected adistinct pattern of specificity with regard to illness-related memories and futureimaginings, whereby individuals with higher health anxiety would tend to showmore specific memories/future imaginings when this was illness-related incontent.

Method

Participants

Sixty psychology undergraduate university students participated in return for coursecredit (19 males and 41 females; mean age = 19.2, SD = 2.69). Participants enrolled inthe study via an online (Internet) registration system. Participants varied on their degreeof health anxiety. Total health anxiety scores on the Short Health Anxiety Inventory(SHAI) ranged from 3 to 33 overall, with n = 21 (35%) of the total sample meeting theclinical cut-off for health anxiety. There were no significant differences between the twoexperimental groups on any of the key demographic factors or baseline measures (seeTable 1 for demographics by experimental group).

Materials

Short Health Anxiety Inventory (SHAI)

The 18-item SHAI assesses health anxiety independent of actual physical health, and hasbeen well validated among nonclinical populations (Fergus & Valentiner, 2011;Salkovskis, Rimes, Warwick, & Clark, 2002). It includes 14 items derived from the

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original 64-item Health Anxiety Inventory, in addition to the 4-item Negative Con-sequences (SHAI-NC), which assesses participants’ perceptions of the seriousness andimpact of future illness. Participants respond on a four-point (0–3) scale. A total scale cut-off score of 18 is used to determine clinically significant health anxiety.

Depression, Anxiety, Stress Scales – Short Form

This 21-item scale, consists of three 7-item subscales (depression, anxiety, and stress), hasbeen extensively validated among nonclinical populations (Depression, Anxiety, StressScales – Short Form (DASS-21); Henry & Crawford, 2005; Lovibond & Lovibond,1995), and was incorporated to account for the well-documented effects of depression andother forms of emotional disturbance on OGM (Williams et al., 2007). Participants ratethe frequency of symptoms in the past week on a four-point scale.

Rumination induction

Watkins and Teasdale’s (2004) experiential and ruminative self-focused attentionalmanipulations were used. In both conditions, participants spent 10 minutes contemplatingthe same set of 28 self-focused sentence stems (e.g., “your physical sensations”),randomly presented for 20 seconds each. The initial instructions distinguished the twoconditions, with participants randomized to the experiential condition told to ‘‘Focus yourattention on your experience of’’ and participants in the analytical condition instructed to‘‘Think about’’ each stem (see Supplemental data, Online Resource 1). Participants thenrated the abstract-concreteness of their thinking on a 10-point visual analogue scale(Watkins & Moulds, 2005).

Autobiographical memory test and future imaginings task

The Autobiographical Memory Test (AMT) and Future Imaginings Task (FIT) requireparticipants to recall specific memories or imagine specific future events respectively, in

Table 1. Participant characteristics presented according to experimental group.

Rumination conditionExperiential self-focus

n = 30Analytical (ruminative)

self-focus n = 30

Number of females 20 (66.6%) 21 (70%)Mean age 18.70 (2.25) 19.73 (3.02)SHAI total scale score 15.63 (5.67) 17.10 (7.19)SHAI negative consequences score 2.73 (1.78) 3.33 (2.31)SHAI avoidance behaviors 14.27 (12.50) 11.47 (9.76)SHAI reassurance-seeking behaviors 19.43 (9.94) 18.40 (10.56)DASS-21 – Depression subscale 8.67 (6.35) 9.67 (7.07)DASS-21 – Anxiety subscale 8.53 (6.97) 8.87 (7.75)DASS-21 – Stress subscale 14.60 (9.22) 14.80 (7.60)DASS-21 total score 31.80 (20.21) 33.33 (17.82)Personal/family illness history 16 (53%) 22 (73%)

Note: Standard deviations appear in parentheses. None of the demographic factors were significantly different atthe p < .05 level.SHAI, Short Health Anxiety Inventory; DASS-21, Depression, Anxiety, Stress Scales – Short Form.

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response to a cue word (see Supplemental data, Online Resources 2 and 3; Williams et al.,1996). Thirty words were used as cues to prompt participants’ memories and futureimaginings across both the AMT and FIT respectively, which included 10 positive,10 negative, and 10 somatic cues (Supplemental data, Online Resource 4). Two matchedlists of 15 words (with 5 words from each category) were created, and counterbalancedsuch that half of the participants received List A word prompts for the AMT and List Bfor the FIT, and vice versa. Prior to both tasks, participants were given two practice cues.Word presentation was randomized. Participants were given 60 seconds to respond toeach prompt, and responses audio-recorded and scored for specificity and content.Specificity ratings for both the past (AMT) and future (FIT) tasks were coded as beingeither specific, intermediate, or general, according to Williams and colleagues’ (1996)instructions. Content was also rated according to the presence/absence of illness concern(e.g., “Getting chest pains a week ago”, “I suppose just finding lumps on me, any lumps,and being like, ‘Oh my goodness I’ve got cancer’”; see Supplemental data, OnlineResources 5 and 6). A second independent rater coded 20% of AMT and FIT responsesand adequate interrater reliability was achieved (mean k reliability coefficient was .87 forAMT specificity and .89 for content, and.86 for FIT specificity and .87 for content).

Personal/family history of illness

Participants were asked, “Have you, or anyone in your immediate family, been diagnosedwith any of the following?” Response options included cancer, cardiovascular disease,diabetes, chronic pain, glandular fever, or “other serious or chronic illness” (to bespecified by participants).

Procedure

Following written informed consent, participants completed the DASS-21 and SHAI,followed by their randomly assigned self-focus induction. Participants then completed theAMT and FIT, with the order of administration of these two tasks counterbalanced acrossparticipants. Following this, participants reported their personal/family history of illness.This was done at the end of the experiment so as not to alert participants to the healthfocus of the study. Finally, participants were thanked, and debriefed as to the general aimsof the study.

Analytic strategy

Analyses were conducted using the IBM Statistical Package for the Social Sciences(SPSS) Version 21.0. Across both the AMT and FIT, analysis of variance (ANOVA) wasundertaken to determine main effects for the outcomes of interest (specificity and illness-concerned content). Subsequent analyses were also planned to examine the specificity ofmemories and future imaginings coded as illness-related in content. These analyses aimedto examine the impact of rumination on specificity of illness-related thinking, given theclinical relevance of this in the context of health anxiety. Finally, hierarchical multipleregression analyses were undertaken across both tasks to examine the predictors ofovergeneral, illness-concerned thinking, taking participant factors such as illness history

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and depression symptoms into account, and using health anxiety as a continuouspredictor.

Results

On the post-self-focus manipulation check, participants in the rumination conditionreported significantly more abstract, and less concrete, thinking (M = 60.69, SD = 19.44),compared with the experiential group (M = 48.21, SD = 19.06; F(1,56) = 5.978, p = .018).

Autobiographical memory responses

Separate ANOVAs indicated no significant effects of rumination on the specificity ofmemories generated in response to positive (F(1,56) = .075, p = .785) or negative (F(1,56) =.143, p = .707) word prompts overall. Regarding illness-related content, analysesindicated that participants recalled an average of 2.15 (SD = 1.27) memories that wereillness-related in content (range: 0–5) and this did not significantly differ betweenparticipants in the ruminative and experiential self-focus conditions (F(1,56) = .499,p = .483). A bivariate correlation examining the association between SHAI total scoreand the number of memories coded as illness-concerned was nonsignificant (r = .133,p = .310), indicating that health anxiety levels were not significantly associated with agreater or lesser degree of illness-concerned remembering per se. In terms of illness-related content, the secondary ANOVA of specific, illness-concerned memories indicateda significant main effect of ruminative thinking (F(1,56) = 5.528, p = .022). Participantswho received the rumination induction reported more specific illness-related memoriesthan did participants who received the experiential induction.

Predictors of illness-related memory

To examine the extent to which participant and cognitive factors accounted for specificand categoric illness-concerned memories respectively, two hierarchical multiple regres-sion analyses were conducted. In each, personal/family illness history, DASS-21depression symptoms, engagement in catastrophic perceptions of the threat of futureillness (SHAI-NC score), and ruminative thinking were entered in steps 1, 2, 3, and 4,respectively.

Prior to undertaking these regression analyses, multicollinearity tests were conductedusing an iterative process of examining variance inflation factor (VIF) values for allindependent variables. There is some consensus regarding a threshold of 3 or lower foracceptable VIF values (Hair, Black, Babin, & Anderson, 2009; Montgomery & Peck,1982). Across all independent variables VIF values ranged from 1.02 to 1.49 across alliterations, indicating little evidence for problematic multicollinearity among variables.

The final significant regression model predicting specific illness-concerned memoriesis presented in Table 2. Ruminative thinking emerged as the sole significant predictor ofspecific illness-related memories (F(1,55) = 6.051, p = .017). Thinking in a ruminativemanner led participants to generate more specific, illness-related memories, above andbeyond the influence of health anxiety, personal illness history, and depression symptoms.None of the variables entered in the model significantly predicted categoric illness-relatedmemories.

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Future imaginings

Separate ANOVAs were again conducted to examine the impact of ruminative thinkingon specific and categoric future imaginings, and indicated no significant effects acrosspositive (F(1,56) = .196, p=.659), or negative (F(1,56) = .655, p = .422) word promptsoverall. Overall, participants recalled an average of 2.03 (SD = 1.38) memories that wereillness-related in content (range: 0–5) and this did not significantly differ between theruminative and experiential self-focus conditions (F(1,56) = .1.744, p = .192). However, asmall, significant bivariate correlation between SHAI total scores and the number offuture imaginings coded as illness-concerned indicated that higher health anxiety wasassociated with participants generating more illness-concerned future imaginings(r = .275, p = .034). A secondary analysis of specific, illness-related future imaginingsindicated a significant main effect (F(1,56) = 5.744, p = .020); ruminative, compared toexperiential, self-focus led to illness-related future imaginings that were more categoric,and less specific in nature.

Relationship between memory and future imaginings

Two planned bivariate correlations examined the relationship between the specificity ofmemory and future thinking. The first correlation, between the total specificity score theAMT and the FIT (across all word prompt categories), indicated a moderate associationbetween the two; participants who generated more specific memories tended to alsogenerate more specific future imaginings (r = .448, p = .000). A second, significantcorrelation demonstrated the same relationship, though to a lesser degree, between thespecificity of illness-related memories and illness-related future imaginings (r = .267,p = .039).

Predictors of illness-related future thinking

Two hierarchical multiple regression analyses were conducted to predict both specific,and categoric, illness-related future imaginings in turn. The same predictors were used asabove, with the addition of participants’ specificity scores for memories coded as illness-concerned in nature. This final predictor was added in order to determine to what extentpatterns of illness-concerned memory predicted overgeneral illness-concerned futurethinking, above and beyond other participant factors.

Table 2. Summary of final hierarchical regression step for the specificity of illness-focusedmemories.

Outcome Variables B SE B β ΔR2 ΔF t p

No. of specificillness-concernedmemories*

Rumination .567 .230 .307 .094 6.051 2.460 .017SHAI-NC .048 .057 .108 .011 .722 .850 .399Illness history −.067 .247 −.037 .001 .073 −.270 .788DASS-21-D −.006 .018 −.020 .002 .121 −.348 .729

Notes: SHAI-NC, Short Health Anxiety Inventory-Negative Consequences; DASS-21-D, Depression, Anxiety,Stress Scales – Short Form Depression subscale score.*Final model significant at the p < .05 level (F(1,55) = 6.051, p = .017).

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In the first regression analysis predicting participants’ proportion of specific illness-related future imaginings, none of the entered variables emerged as significant predictors.In the second regression analysis, several variables predicted categoric, illness-relatedfuture imaginings, however. Table 3 presents the summary statistics for the final step ofthis analysis (F(1,56) = 6.517, p = 0.003). Rumination, and having more catastrophic,health anxious views of the threat of future illness (SHAI-NC scores) together predictedmore categoric illness-related future thinking (accounting for 19% of the variance).Participant illness history, depression symptoms, and participants’ specificity scores forillness-concerned memories did not add to this explained variance.

Discussion

This study examined the impact of ruminative thinking among individuals with varyingdegrees of health anxiety. Our hypotheses were partially supported. No significant effectsof rumination or degree of health anxiety on overgeneral memory/future thinkingemerged, across all content types (Hypotheses 1 and 3). However, several significanteffects emerged for illness-concerned thought content, although the direction of theseeffects was only partially consistent with Hypothesis 4. Rumination led to illness-relatedmemories that were more specific in nature. However, rumination predicted morecategoric illness-concerned future thinking, As such, rather than contributing to moreovergeneral thinking in a uniform way, rumination appeared to lead to distinct effects onthe specificity of past, versus future, illness-related thinking. Finally, when ruminationwas combined with catastrophic cognitions regarding future illness (a key aspect of healthanxiety), this accounted for significantly more overgeneral illness-concerned futurethinking. This suggests that, in addition to greater health anxiety leading to quantitativelymore illness-concerned future imaginings (consistent with Hypothesis 2), ruminativethinking may further potentiate the tendency for individuals with higher health anxiety togenerate illness-concerned future imaginings in a qualitatively different manner (i.e., morecategoric).

The distinct effects of rumination on (specific) past and (categoric) future illness-related thinking can be understood in the context of health anxiety. For health anxiousindividuals, illness-related memories are likely to be preferentially recalled due to theircompatibility with their current view of themselves (as someone especially vulnerable toillness) and their future goals (to prevent the catastrophic effects of future, impending

Table 3. Summary of final hierarchical regression step for the specificity of future illness-focusedimaginings.

Outcome Variables B SE B β ΔR2 ΔF t p

No. of overgeneralillness-concernedfuture imaginings*

SHAI-NC .185 .069 .332 .110 7.194 2.682 .010Rumination .636 .276 .278 .076 5.305 2.303 .025Illness history −.324 .289 −.137 .018 1.254 −1.120 .267DASS-21-D .030 .021 .173 .028 2.018 1.420 .161AMT specificityscore

−.012 .050 −.029 .001 .053 −.231 .818

Notes: SHAI-NC, Short Health Anxiety Inventory-Negative Consequences; DASS-21-D, Depression, Anxiety,Stress Scales – Short Form Depression subscale score; AMT, Autobiographical Memory Test.*Final model significant at the p < .01 level (F(1,56)= 6.517, p = .003).

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illness) (Conway & Pleydell-Pearce, 2000). The increased specificity with which illness-related memories are recalled in health anxious individuals reflects the personal salienceof these past exemplars of illness occurrence. This finding is consistent with recentfindings indicating that for memories integrally related to the subject of a person’sdistress, the “prepotency” of these prevents the typical OGM effect from occurring, andcan result in specific retrieval of these personally salient experiences (Golden et al.,2007). Preoccupation with, and elaboration of, past illness-related memories may thereforeserve to fuel ongoing health anxiety in the present, and maintain these memories in avivid, and highly salient form.

By contrast, the categoric illness-focused future imaginings seen as a result ofrumination may reflect cognitive avoidance as a means of emotion regulation (Cameron,2003). Illness-related future imaginings are likely to be more threatening to healthanxious individuals in their specific rather than categoric form. For example, imagining“sitting in my doctor’s office next month and hearing her tell me that the lump in mybreast is cancer” may be more potent than picturing, “maybe getting some disease in thefuture” due to the vivid images and intense emotions the specific imagining evokes. Thecombination of illness-related thinking which is both specific in the past, yet overgeneralin the future, may serve to maintain health anxiety as individuals experience vividreminders of their past vulnerability to illness, yet are unable to clearly envisage how theywould cope with illness in the future. These cognitive biases may fuel ongoing health-related avoidance behaviors, and may potentially contribute to a reduced capacity forhealth-related problem solving.

In line with past research, a small correlation was detected between the specificity ofpast and future thinking. However, when ruminative thinking and health anxiety weretaken into account, memory specificity no longer predicted specific future illness-relatedthinking. Rumination alone accounted for the specificity of illness-concerned memories.Rumination appears to trigger negative self-schemas (Lyubomirsky, Caldwell, & Nolen-Hoeksema, 1998), and has been linked to the repeated re-experiencing of intrusivememories related to past adverse events in clinical populations (e.g., in obsessivecompulsive disorder; Speckens, Hackmann, Ehlers, & Cuthbert, 2007). In health anxiety,ruminative thinking is likely to activate concepts of personal vulnerability to futureillness. While health anxiety symptoms did not account for the specificity of illness-related memories, we found that aspects of health anxiety (catastrophic beliefs aboutfuture illness), together with ruminative thinking, best predicted more overgeneral,categoric future illness-related thinking. This may reflect processes of cognitiveavoidance. However, this finding could equally reflect an inability to generate specificfuture imaginings due to participants’ cognitive capacity being taken up with ongoingruminative thinking processes. Both of these potential explanations are consistent withrecent models of autobiographical memory specificity (Williams, 2006). Future researchmay focus on distinguishing between these potential mechanisms.

Study limitations

This study contributes to the literature one of the first experimental examinations of theimpact of ruminative thinking among individuals with varying degrees of health anxiety.However, the generalizability of this study’s findings may be limited by its small,nonclinical student sample. As health anxiety and clinical hypochondriasis are proposed

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to lie along a continuum varying only dimensionally, by severity, this approach seemsjustifiable for the purposes of delineating key cognitive mechanisms (Ferguson, 2009).However, whether (and to what extent) these mechanisms might drive adaptation amongindividuals with imminent, life-threatening, or chronic health concerns remains unclear.Consequently, future studies should extend these findings to clinical hypochondriasispopulations, as well as medically ill individuals.

We also recognize that the assessment of memories and future imaginings occurred inthe same experimental session, which may have influenced the interdependency of thesetwo reports. Assessing them in distinct contexts may provide for a more sensitive indexof the relationship between past and future representations of health concerns. It may alsohave been beneficial to obtain a baseline assessment of memory/future thinkingspecificity, although there was no evidence to suggest that this should differ betweenthe groups.

Future research directions

The current findings offer several implications deserving of further attention. Forexample, if overgeneral illness-related future thinking forms part of an avoidant responseto the sense of illness-related vulnerability activated by ruminative thinking, then futurestudies might investigate the effects that might have in turn on other health-relevantoutcomes such as information- and reassurance-seeking, as well as other health-relatedbehaviors (e.g., doctor’s check-ups, breast/testicular self-examinations). Future studiesmight also examine the relationship between overgeneral illness-related future thinkingand the maintenance of intrusive imagery, and whether ruminative thinking plays amediational role in this.

In this study, while rumination led health anxious participants to experience morecategoric illness-related future thinking, health anxious individuals who engaged in anexperiential self-focus did not show this effect. This finding underscores the relevance ofmindfulness in the treatment of health anxiety, such as in the context of MBCT(McManus et al., 2012). Proponents of MBCT have already highlighted its potential tomitigate the ruminative thought processes that may perpetuate health anxiety (McManuset al., 2012; Segal et al., 2002). This study adds the notion that rumination mayexacerbate health anxiety via its effects on overgeneral, illness-related future thinking inthe face of ongoing health-related concerns. Future research among clinical populations isneeded to explore this further.

These findings also have a number of clinical implications for health anxiety in othercontexts, such as in cancer survivorship. Ruminative thinking has already been suggestedas one factor that may perpetuate fear of cancer recurrence (Lee-Jones, Humphris, Dixon,& Hatcher, 1997). This study implicates rumination as a viable process to address ininterventions. Targeting individuals’ use of overgeneral, illness-related future thinking asa cognitive avoidance strategy may be useful. Imagery rescripting is one experientialtechnique that has been used in a range of disorders to train individuals to switch fromovergeneral, ruminative thinking, to a more experiential, specific mode of thinking(Brewin et al., 2009; Speckens et al., 2007; Wheatley & Hackmann, 2011). As withexposure therapy, applying such techniques to illness concerns could involve assisting theindividual to imagine future illness events in detail, using flash-forward techniques toimagine and “re-script” specific ways that they could cope with the imagined health event

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(Muse et al., 2010). In the cancer domain, such tailored techniques might be used to assistsurvivors to navigate the crucial task of coping adaptively with the ongoing anxiety-provoking, yet realistic, threat of cancer in the face of ubiquitous reminders of this (e.g.,Jones, Parker-Raley, & Barczyk, 2011; Zebrack, 2000).

Supplemental data

Supplemental data for this article can be accessed here.

Note1. Throughout this paper, hypochondriasis refers specifically to the clinical syndrome, whereas

health anxiety refers to full range of dysfunctional health concerns.

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