Cogn Ther Res (2011) 35:566–574
DOI 10.1007/s10608-011-9354-2
BRIEF REPORT
The Short Health Anxiety Inventory and Multidimensional
Inventory of Hypochondriacal Traits: A Comparison
of Two Self-Report Measures of Health Anxiety
Thomas A. Fergus • David P. Valentiner
Published online: 24 February 2011
Ó Springer Science+Business Media, LLC 2011
Abstract Using data from a large nonclinical sample
(N = 503), the current study examined the convergence
and utility of the Short Health Anxiety Inventory (SHAI;
Salkovskis et al., in Psychol Med 32:843–853, 2002) and
the Multidimensional Inventory of Hypochondriacal Traits
(MIHT; Longley et al., in Psychol Assess 17: 3–14, 2005).
Results from a higher-order measurement model indicated
that the SHAI and the MIHT factors were distinguishable
and generally shared significant intercorrelations. The
affective factor of the SHAI and the MIHT shared the
strongest convergence and the MIHT cognitive factor
clustered with both affective factors. Further, a higher-
order health anxiety factor adequately accounted for SHAI-
MIHT factor intercorrelations, with the affective and
cognitive factors of the SHAI and the MIHT loading
strongest upon the higher-order factor. Finally, only the
affective and cognitive SHAI and MIHT scales incremen-
tally contributed—beyond general distress and the other
SHAI and MIHT scales—in regression analyses predicting
medical utilization and somatic symptoms. Implications for
the conceptualization and assessment of health anxiety are
discussed.
Keywords Hypochondriasis
Health anxiety
Self-report
measures
Medical utilization
Somatic symptoms
T. A. Fergus
D. P. Valentiner (&)
Department of Psychology, Northern Illinois University,
DeKalb, IL 60115, USA
e-mail: dvalentiner@niu.edu
123
Introduction
The Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR; American Psychiatric Association [APA],
2000) places hypochondriasis (HC) with the somatoform
disorders, but contemporary theorists view the disorder as
being better represented as an extreme form of health
anxiety and belonging to the anxiety disorders domain
(Olatunji et al. 2009). Support for considering HC an
anxiety disorder comes from data indicating that variables
important to the phenomenology of anxiety disorders,
panic and obsessive–compulsive disorder in particular, are
also relevant to HC (e.g., anxiety sensitivity, body vigi-
lance, intolerance of uncertainty; Deacon and Abramowitz
2008). Further, the behavioral component of HC (i.e.,
reassurance seeking) appears to serve a similar function as
the avoidance behaviors seen in anxiety disorders
(Abramowitz and Moore 2007). To gain greater insight into
HC, as conceptualized as health anxiety, valid self-report
measures are needed. However, ‘‘research on HC and
health anxiety has been hampered by the lack of a con-
sensus measure for assessing this problem from a cogni-
tive-behavioral perspective’’ (Wheaton et al. 2010, p. 566).
It thus remains necessary to examine the utility of extant
health anxiety measures.
Self-Report Measures of Health Anxiety
Whereas the Whiteley Index (Pilowsky 1967) and the Ill-
ness Attitudes Scale (Kellner 1986) have been two of the
most commonly used self-report measures of HC, these
two measures were designed to be consistent with the
conceptualization of HC as a somatoform disorder (Hiller
et al. 2002). Two more recently developed self-report
measures purportedly assess HC in a manner consistent
Cogn Ther Res (2011) 35:566–574
with contemporary viewpoints that it represents an extreme
form of health anxiety.
Short Health Anxiety Inventory (SHAI; Salkovskis et al.
2002)
The SHAI is an 18-item short-form of the original 64-item
Health Anxiety Inventory (HAI; Salkovskis et al. 2002). In
constructing the SHAI, Salkovskis et al. took the 14 items
from the HAI that had the highest item-total correlation in
a sample of HC patients and used these items as the basis of
the SHAI. Salkvoskis et al. then created and added four
additional items based upon theoretical considerations. A
two-factor solution best represents the SHAI items in both
nonclinical and clinical samples (Abramowitz et al. 2007b;
Wheaton et al. 2010). These two SHAI factors are (a) ill-
ness-likelihood, which assesses affective concerns about
acquiring a serious illness (e.g., I spend most of my time
worrying about my health), and (b) illness severity, which
assesses the feared burden of obtaining a serious illness
(e.g., A serious illness would ruin every aspect of my life).
Across studies, researchers have found that the SHAI
scales possess adequate internal consistency and generally
share stronger correlations with similar than dissimilar
constructs. Also, higher mean-level SHAI scores have been
found in individuals suffering from HC relative to indi-
viduals suffering from a non-HC anxiety disorder and
nonclinical controls (Abramowitz et al. 2007b; Salkovskis
et al. 2002; Wheaton et al. 2010). However, one study
found the SHAI scales to be redundant with a measure of
HC (i.e., the Illness Attitudes Scale) in predicting a
behavioral component of the disorder (i.e., medical utili-
zation; Fergus and Valentiner 2009). Further, the conver-
gence of the SHAI scales with a measure that was designed
to be consistent with the conceptualization of HC as health
anxiety remains unexamined.
Multidimensional Inventory of Hypochondriacal Traits
(MIHT; Longley et al. 2005)
In developing the MIHT, Longley et al. constructed items
that were written to be consistent with dimensions assessed
by prior measures of HC and contemporary conceptual-
izations of the disorder representing an extreme form of
health anxiety. Thirty-one items were selected from a large
initial pool of items, and these 31 items were then exposed
to an exploratory factor analysis. This analysis yielded four
factors, including (a) alienation (cognitive dimension),
which assesses perceptions of others being unsympathetic
to one’s disease conviction (e.g., I wish others took my
health complaints more seriously), and (b) reassurance
(behavioral dimension), which assesses the tendency to
seek reassurance for health concerns (e.g., I like to be
567
reassured when I feel sick). The two other factors were
(c) absorption (perceptual dimension), which assesses
attention to physical sensations and body position (e.g., I
am aware of my body position), and (d) worry (affective
dimension), which assesses affective responses to health
concerns (e.g., I worry a lot about my health). Subsequent
confirmatory factor analyses supported the adequacy of this
four-factor solution (Longley et al. 2005; Stewart et al.
2008).
Results from Longley et al. (2005) further indicated that
the MIHT scales possess adequate internal consistency and
generally share stronger relations with similar than dis-
similar constructs. Some of the MIHT scales also accoun-
ted for significant unique variance in scores of health care
usage (e.g., number of clinics visited) and self-reported
somatic symptoms, even after controlling for general dis-
tress. However, no known studies have examined the
associations between the MIHT scales and another measure
designed to be consistent contemporary conceptualizations
of HC, as health anxiety, or whether the MIHT scales
incrementally contribute—beyond a measure of health
anxiety—in the prediction of HC-related criteria.
Key Issues from Extant Literature
The SHAI and the MIHT are promising measures of health
anxiety, but important characteristics of both measures
remain unexamined. For example, it would be particularly
informative to consider the overlapping and distinct fea-
tures of these two measures, as the SHAI and the MIHT
were developed to tap different perspectives of health
anxiety (Olatunji 2008). That is, whereas the SHAI was
developed to assess health anxiety from solely a cognitive-
behavioral perspective, the MIHT was developed to tap
facets of health anxiety as conceptualized from both a
cognitive-behavioral and an interpersonal perspective.
More specifically, MIHT-alienation (cognitive dimension)
was created to be consistent with the viewpoint that mal-
adaptive attempts to gain comfort and a sense of security
from others underlie the disease conviction seen in HC
(Stuart and Noyes 1999).
To assess their overlapping and distinct features, SHAI-
MIHT relations were initially examined via a higher-order
measurement model. The use of a higher-order measure-
ment model allowed us to examine four important SHAI-
MIHT characteristics. First, it allowed us to examine the
differentiation of the SHAI and the MIHT factors by
examining whether a one-factor first-order model or a six-
factor first-order model best represented the SHAI and the
MIHT items. Given the relatively unique item content of
both measures, we expected a six-factor model would
provide a superior fit to the data relative to a one-factor
model.
123
568
Second, should a six-factor first-order model appear
superior, this model would allow us to examine SHAI-
MIHT latent relations. Latent relations take measurement
error into account (e.g., scale unreliability), and thus these
relations should provide a clearer estimate of SHAI-MIHT
associations (Brown 2006). SHAI-illness likelihood and
MIHT-worry were expected to share the strongest relation,
as both dimensions purportedly assess an affective
dimension of health anxiety. SHAI-illness severity and the
other MIHT dimensions (alienation, reassurance, and
absorption) were expected to share more modest intercor-
relations with the other health anxiety dimensions, as these
four dimensions appear to assess relatively distinct content.
Third, the higher-order measurement model allowed us
to examine whether the common underlying construct that
both the SHAI and the MIHT purportedly assess (i.e.,
health anxiety) accounts for their relations. That is, there
appeared to be sufficient theoretical evidence to suggest the
presence of a higher-order factor (i.e., a global health
anxiety factor) that would account for SHAI-MIHT latent
intercorrelations. Fourth, if a higher-order model ade-
quately represents SHAI-MIHT latent interrelations, then
the relative importance of each SHAI and MIHT first-order
factor to the global health anxiety factor could be examined
via the magnitude of the factor loading of each first-order
factor on the higher-order factor.
The current study also examined the incremental
validity of the SHAI and the MIHT scales, as tests of
incremental validity can shed light about the importance of
the distinct constructs assessed by these two measures. The
SHAI and the MIHT scales were expected to incrementally
contribute to the prediction of HC-related criteria, as both
measures were developed based upon different perspec-
tives. Based upon results from prior studies, SHAI-illness
likelihood and MIHT-alienation were expected to be the
most robust unique predictors of the HC-related criteria
from each measure (Abramowitz et al. 2007a; Longley
et al. 2005). Medical utilization was one of the HC-related
criteria selected for the current study, as it represents a
central way in which individuals with HC attempt to gain
reassurance that they are medically healthy (Abramowitz
et al. 2002). Somatic symptoms represented the other HC-
related criteria, as the over-reporting of somatic symptoms
may be an important factor in the elevated medical utili-
zation associated with the disorder (Longley et al. 2005).
Although studying carefully diagnosed patients with HC
is important, SHAI-MIHT relations were investigated
using a nonclinical sample. Studying HC-related phenom-
ena in nonclinical populations reduces the extent to which
(a) HC is confounded with actual physical health problems
(Abramowitz et al. 2007a) and (b) co-occurring disorders
and the overrepresentation of disease conviction obscure
relationships (Noyes et al. 2004). It is also consistent with
123
Cogn Ther Res (2011) 35:566–574
Longley et al. (2010), who found support for the dimen-
sionality (i.e., non-taxonic nature) of HC and concluded
HC should be investigated using unselected samples. In
sum, examining HC in nonclinical samples is consistent
with the broader literature interested in better understand-
ing the disorder.
Method
Participants and Procedure
The sample consisted of 503 undergraduate college stu-
dents enrolled in an introductory psychology class at a
Midwestern university. The sample had a mean age of 19.1
(SD = 2.3) years, and was predominantly female (67.7%)
and Caucasian (69.2%).
Participants completed the fixed-order questionnaire
packets in small group sessions in a university classroom.
Data for this IRB-approved study were collected anony-
mously and participants were informed that they were free
to withdraw from the study at any time.
Measures
Short Health Anxiety Inventory (SHAI; Salkovskis et al.
2002)
The SHAI examines health concerns independent of actual
physical health status. Responses are given on a 4-point
scale, with response choices varying based on the question.
Following the recommendations of Wheaton et al. (2010),
item 13 of the SHAI was not used in the subsequently
described analyses because of its salient cross loading on
both SHAI factors.
Multidimensional Inventory of Hypochondriacal Traits
(MIHT; Longley et al. 2005)
The MIHT assesses attitudes towards health using a 5-point
scale.
Medical Utilization Questionnaire—Previous Month Scale
(MUQ; Abramowitz et al. 2007a)
The MUQ-previous month scale assesses the number of
times respondents have engaged in 10 different safety-
seeking behaviors because of concern for their health
during the past month on a 5-point scale. This scale has
demonstrated adequate psychometric properties and has
been used as an index of medical utilization in prior studies
(Abramowitz et al. 2007a; Fergus and Valentiner 2009,
2010).
Cogn Ther Res (2011) 35:566–574
Hopkins Symptom Checklist (HSCL; Derogatis et al. 1974)
The HSCL is a 58-item measure that asks respondents to
describe how much discomfort a variety of symptoms have
caused them during the past week, including the present
day, by using a 4-point scale. The measure contains scales
assessing a variety of symptoms, including a 12-item scale
that assesses the presence of somatic symptoms (i.e.,
HSCL-somatization). HSCL-somatization is a commonly
used measure of somatic symptoms, and it has demon-
strated adequate psychometric properties in prior studies
(Kroenke 2007).
Positive and Negative Affect Schedule (PANAS; Watson
et al. 1988)
The PANAS is a 20-item measure that asks respondents to
indicate how they have felt over a given timeframe on a
5-point scale. The scale contains 10 items assessing each
positive and negative affect. The negative affect scale of
the PANAS (i.e., PANAS-NA)—the PANAS scale of
interest in the present study—has demonstrated adequate
psychometric properties in prior studies, and trait-like (i.e.,
general) time instructions were used (Watson et al. 1988).
Data Analytic Strategy
A higher-order measurement model, following Brown
(2006), was used to examine SHAI-MIHT relations. Both a
one- and a six-factor first-order model were tested first. The
one-factor model consisted of all of the SHAI and the
MIHT items loading on a single factor. Indicators of the
SHAI and the MIHT factors within the six-factor model
were the items that have shown primary salient loadings on
the respective SHAI and MIHT factors (see Longley et al.
2005; Wheaton et al. 2010). The SHAI and MIHT factors
were allowed to intercorrelate in this six-factor model.
Given the expected superiority of the six-factor first-order
model, a second-order model was tested next. This second-
order model removed the first-order SHAI-MIHT inter-
correlations within the six-factor first-order model and
added direct effects from the higher-order factor to each of
the SHAI and MIHT first-order factors.
These models were tested using LISREL 8.54 (Jöreskog
and Sörbom 2003) and by using robust maximum likeli-
hood estimation (Satorra and Bentler 1994), in which
covariance and asymptotic covariance matrices were
inputted to avoid any concerns surrounding the influence of
data non-normality on maximum likelihood estimation
(Brown 2006). Four of the most recommended (Brown
2006; Hu and Bentler 1999) fit indices were used to eval-
uate the models: the comparative fit index (CFI), the non-
normed fit index (NNFI), the root mean square error of
569
approximation (RMSEA), and the standard root mean
square residual (SRMR). Hu and Bentler’s guidelines
stating that the CFI and NNFI should be close to .95, the
RMSEA should be close to .06, and the SRMR should be
close to .08 to indicate an adequate fit were used.
The scaled difference in v2s test (SDCS; Satorra and
Bentler 2001) was initially used to examine the difference
in fit between the one- and six-factor first-order models and
between the six-factor first-order model and the second-
order model (see Rindskopf and Rose 1988, for review as
to how one-factor models are special cases of second-order
models). Given evidence to suggest that significant chi-
square difference tests are found even when differences
among models are ‘‘trivial’’ (Cheung and Rensvold 2002),
we also examined the 90% RMSEA confidence interval
(CIs) of the first- and second-order models. Differences in
model fit are considered non-significant if models have
overlapping 90% RMSEA CIs (see Raykov and Penev
1998, for description; see Wang and Russell 2005, for
application).
Zero-order Pearson correlations were computed to
examine the interrelations among the study variables. Two
sets of hierarchical regressions were then used to examine
the incremental validity of the SHAI and the MIHT scales
in predicting MUQ-previous month and HSCL-somatiza-
tion scores. PANAS-NA was entered into Step 1 of both
sets of hierarchical regressions, as general distress relates
strongly to both medical utilization and somatic symptoms
(Longley et al. 2005). The SHAI and the MIHT scales were
then entered into Step 2 and Step 3 of both sets of hier-
archical regressions, with the order of entry switched such
that the amount of incremental variance associated with
each set of scales could be evaluated. Given the content
overlap between MIHT-reassurance and medical utilization
(Longley et al. 2005), this MIHT scale was not included in
the hierarchical regression model predicting MUQ-previ-
ous month scores.
Results
Missing Data and Health Status
Twelve participants (2.4% of the total sample) frequently
omitted responses (i.e., greater than 15% of possible items)
on at least one measure and were removed from subsequent
analyses. Following the recommendations of Abramowitz
et al. (2007a), the 46 participants (n = 491; 9.4%) in the
remaining sample that reported having a current diagnosed
physical illness were removed from subsequent analyses.
This procedure was used in an attempt to ensure that cur-
rent physical health minimally contributed to observed
levels of health anxiety. The most common physical
123
570
illnesses were asthma (n = 13; 28.3%), followed by dia-
betes (n = 4; 8.6%). The results described below were
using the remaining 445 participants.1
There existed only a small number of missing data
points among the remaining 445 participants (missing data
point percentages ranged from 0.00 to 0.19% for each
measure). Two-way imputation for normally distributed
errors (TW-E; Bernaards and Sijtsma 2000) and two-way
imputation for separate scales (TW-SS; van Ginkel et al.
2007) were used to impute estimated values for these data
points. TW-E is used for one-factor measures and TW-SS
is used for factorially complex measures, and both are
effective procedures for imputing missing data when there
is a relatively small number (around 5% or less) of missing
data points for a measure (Bernaards and Sijtsma 2000; van
Ginkel et al. 2007).
First-Order Measurement Model
The one-factor model was tested first and it did not provide an
adequate fit to the data [v2 = 7,537.5; Satorra-Bentler (SB)
v2 = 6,518.5 (df = 1,080, P \ .01); CFI = .86; NNFI =
.87; RMSEA = .11 (90% CI = .104–.109); SRMR = .10];
none of the goodness-of-fit indices met or exceeded the
specified guidelines. The six-factor model was tested next and
it provided an adequate fit to the data [v2 = 2,389.4; Satorra-
Bentler (SB) v2 = 2,072.6 (df = 1,065, P \ .01); CFI = .95;
NNFI = .95; RMSEA = .05 (90% CI = .043–.049);
SRMR = .07]; all of the goodness-of-fit indices met or
exceeded the specified guidelines. Further, both the SDCS test
[SDCS v2 = 3,669.6 (df = 15, P \ .01)] and their non-
overlapping 90% RMSEA CIs indicated that the one-factor
model provided a significantly poorer fit to the data compared
to the six-factor model.
All of the factor loadings within this six-factor first-
order model were significant (P \ .01).2 All of the
1
23.6% (105/445) of participants scored at or above the SHAI total
scale cutoff score of 18, which includes item 13 of the SHAI in its
computation, suggested by Rode et al. (2006) to identify individuals
with clinically elevated HC symptoms. Such scores suggest that a
number of respondents experienced phenomena relevant to HC in the
current study. The mean SHAI total scale score was 13.1 (SD = 6.9)
in the current study.
2
The average completely standardized factor loadings were as
follows: SHAI-illness likelihood = .54 (range = .17–.68); SHAI-
illness severity = .63 (range = .52–.69); MIHT-alienation = .70
(range = .49–.78); MIHT-reassurance = .59 (range = .31–.69);
MIHT- absorption = .56 (range = .39–.69); MIHT-worry = .63
(range = .52–.77). Complete listings of these factor loadings are
available upon request. Although items 2 and 3 of the SHAI had
loadings below conventional guidelines for salient loadings on the
SHAI-illness likelihood factor (e.g., below .30; Brown 2006), these
items were retained to allow for greater comparability of the current
results with other studies using the SHAI.
123
Cogn Ther Res (2011) 35:566–574
correlations among the SHAI and the MIHT latent factors
were significant (P \ .05), except the correlation between
the SHAI-illness severity and the MIHT-absorption factors,
and are presented in Table 1. The SHAI-illness likelihood
and the MIHT-worry factors shared the strongest correla-
tion, supporting the notion that both factors tap an affective
dimension of health anxiety. The MIHT-alienation factor
clustered with these two factors, whereas the SHAI-illness
severity and both the MIHT-reassurance and the MIHT-
absorption factors tended to share relationships more
modest in magnitude with the other factors.
Second-Order Measurement Model
The second-order model was tested next and it provided an
adequate fit to the data [v2 = 2,549.7; SB v2 = 2,203.3
(df = 1,074, P \ .01); CFI = .95; NNFI = .95;
RMSEA = .05 (90% CI = .046–.052); SRMR = .05]; all
of the goodness-of-fit indices met or exceeded the specified
guidelines. Whereas, the SDCS test indicated that the
second-order model provided a significant decrement in
model fit compared to the six-factor first-order model
[SDCS v2 = 95.8 (df = 9, P \ .01)], their overlapping
90% RMSEA CIs indicated there was no significant dif-
ference in fit between these two models. Based on its
goodness-of-fit indices and 90% RMSEA CI, the second-
order model was considered to adequately account for
SHAI-MIHT factor intercorrelations. The first- and second-
order factor loadings were all significant (P \ .01) in
this higher-order model and the completely standardized
loadings on the second-order factor were: SHAI-illness
likelihood = .83; SHAI-illness severity = .51; MIHT-
alienation = .71; MIHT-reassurance = 55; MIHT-absorp-
tion = .42; and MIHT-worry = .96.3
Correlations among the SHAI and the MIHT Scales
Table 1 presents descriptive statistics and correlations
among the study variables.
The SHAI and the MIHT scales shared intercorrelations
that mirrored their factor correlations. That is, the strongest
correlation was between SHAI-illness likelihood and
MIHT-worry, and MIHT-alienation clustered with both of
these scales. Further, SHAI-illness severity and both
MIHT-reassurance and MIHT-absorption shared more
modest relationships with the other scales.
3
The average completely standardized factor loadings on the first-order
factors in the higher-order model were as follows: SHAI—illness like-
lihood = .54 (range = .19–.67); SHAI—illness severity = .64
(range = .52–.68); MIHT—alienation = .70 (range = .48–.78);
MIHT—reassurance = .60 (range = .32–.70); MIHT—absorption =
.56 (range = .40–.69); MIHT—worry = .63 (range = .52–.77). Com-
plete listings of these factor loadings are available upon request.
Cogn Ther Res (2011) 35:566–574 571

Table 1 Correlations and descriptive statistics

Factor 1 2 3 4 5 6

1. SHAI-illness –
likelihood
2. SHAI-illness severity .63** –
3. MIHT-alienation .56** .31** –
4. MIHT-reassurance .33** .14* .49** –
5. MIHT-absorption .28** .10 .28** .53** –
6. MIHT-worry .80** .44** .68** .54** .40** –
Scale Mean (SD) 1 2 3 4 5 6 7 8 9

1. SHAI-illness likelihood 9.80 (5.10) (.84)

2. SHAI-illness severity 2.67 (2.18) .49** (.73)
3. MIHT-alienation 14.19 (5.71) .48** .26** (.87)
4. MIHT-reassurance 22.88 (6.73) .28** .09 .41** (.81)
5. MIHT-absorption 29.60 (6.51) .29** .09 .24** .42** (.81)
6. MIHT-worry 16.13 (5.83) .65** .34** .59** .45** .35** (.82)
7. MUQ-previous month 6.46 (5.37) .46** .25** .33** .16** .10* .40** (.81)
8. HSCL-somatization 11.75 (6.37) .40** .22** .27** .25** .22** .41** .27** (.85)
9. PANAS-negative affect 20.85 (6.71) .42** .33** .37** .22** .20** .45** .24** .33** (.85)

Latent factor correlations presented in upper half of table and scale correlations presented in lower half of table. Cronbach’s alpha coefficients
listed in parentheses along the diagonal
SHAI Short Health Anxiety Inventory, MIHT Multidimensional Inventory of Hypochondriacal Traits, MUQ Medical Utilization Questionnaire,
HSCL Hopkins Symptom Checklist, PANAS Positive and Negative Affect Schedule
N = 445. ** P \ .01; * P \ .05 (two-tailed)

Incremental Validity Discussion

Medical Utilization
Table 2 presents the results from the hierarchical regressions
predicting MUQ-previous month and HSCL-somatizaton
scores. Both the SHAI and the MIHT scales predicted sig-
nificant amounts of unique variance (Ps \ .01)—beyond
PANAS-NA and the other set of scales—in MUQ-previous
month scores. Among the SHAI and the MIHT scales, SHAI-
illness likelihood, MIHT-alienation, and MIHT-worry
emerged as significant unique predictors of MUQ-previous
month scores.
Somatic Symptoms
Both the SHAI and the MIHT scales predicted significant
(Ps \ .01) unique variance—beyond PANAS-NA and the
other set of scales—in HSCL-somatization scores. Among
the SHAI and the MIHT scales, SHAI-illness likelihood
and MIHT-worry emerged as significant unique predictors
of HSCL-somatization scores.
The SHAI and the MIHT are two recently developed self-
report measures of HC that purportedly assess the domain in
a manner consistent with contemporary viewpoints that HC
represents an extreme form of health anxiety. Addressing
unexamined issues surrounding the SHAI and the MIHT, the
current study used a higher-order measurement model and
regression analyses to examine SHAI-MIHT relations and
their incremental validity in predicting medical utilization
and somatic symptoms. Results supported the notion that the
SHAI and the MIHT (a) are marked by distinguishable
factors; (b) both assess an affective dimension; and (c) are
representative of the same underlying construct (i.e., health
anxiety). Further, the affective and cognitive SHAI and
MIHT scales were the only scales of each measure that
uniquely predicted HC-related criteria.
Dimensions of HC
Both the diagnostic criteria of HC and researchers
emphasize two core dimensions underlying the disorder: an
affective dimension, marked by disease phobia, and a

123
572 Cogn Ther Res (2011) 35:566–574

Table 2 Results of hierarchical regressions examining predictors of medical utilization and somatic symptoms
Variable Medical utilization Somatic symptoms
Step 1 Step 2 Step 3 Step 1 Step 2 Step 3
D R2 r Partial r Partial r D R2 r Partial r Partial r

Step 1 .06** .11**

PANAS-negative affect .24** .05 .01 .33** .20** .15**
Step 2 .16** .09**
SHAI-illness likelihood .37** .25** .29** .16**
SHAI-illness severity .02 .02 -.01 .00
Step 3 .03** .03**
MIHT-alienation .10* -.03
MIHT-reassurance – .07
MIHT-absorption -.08 .04
MIHT-worry .10* .14**
Step 1 .06** .11**
PANAS-negative affect .24** .06 .01 .33** .18** .15**
Step 2 .12** .09**
MIHT-alienation .13** .10* -.01 -.03
MIHT-reassurance – – .05 .07
MIHT-absorption -.06 -.08 .06 .04
MIHT-worry .24** .10* .23** .14**
Step 3 .06** .02
SHAI-illness likelihood .25** .16**
SHAI-illness severity .02** .01
PANAS-NA Positive and Negative Affect Schedule, SHAI Short Health Anxiety Inventory, MIHT Multidimensional Inventory of Hypochon-
driacal Traits
N = 445. ** P \ .01; * P \ .05

cognitive dimension, marked by disease conviction (APA
2000; Fergus and Valentiner 2010). The current results add
to these extant considerations by finding the affective and
cognitive dimensions to be most relevant to contemporary
viewpoints of HC, as conceptualized as health anxiety.
That is, the affective and cognitive dimensions of the SHAI
and the MIHT tended to show the strongest convergence,
provided the largest contributions to a higher-order health
anxiety factor, and the SHAI and the MIHT scales
assessing these dimensions were the only scales from each
measure that uniquely predicted HC-related criteria.
Longley et al. (2010) called for increased attention to
HC dimensions other than the affective and cognitive
dimensions. Consistent with the cognitive-behavioral con-
ceptualization of HC (Abramowitz et al. 2002), Longley
et al. noted that greater emphasis should be placed on the
perceptual and behavioral dimensions underlying the dis-
order. The current results, however, found that the per-
ceptual and behavioral dimensions added no utility—
beyond general distress and both the affective and cogni-
tive dimensions—in understanding phenomena relevant to
HC. Of note, the current results are consistent with existing
models of HC, in which reassurance seeking is believed to
be chiefly motivated by desires to assuage affective con-
cerns surrounding one’s health (i.e., cognitive-behavioral
perspective; Abramowitz et al. 2002) or maladaptive
attempts to gain comfort and a sense of security from
others (i.e., interpersonal perspective; Stuart and Noyes
1999). These results are also consistent with cognitive-
behavioral theorists, who purport that affective responses
to health concerns engender greater somatic complaints
(Abramowitz et al. 2002).
The current results also do not support the utility of
beliefs regarding the feared burden of having a serious
illness to our understanding of the health anxiety domain,
as SHAI-illness severity did not incrementally contribute to
the prediction of medical utilization or somatic symptoms.
Of note, SHAI-illness severity shared stronger relationships
with the affective and cognitive dimensions than it did with
the perceptual and behavioral dimensions. Although spec-
ulative, perceptions that a future illness would be particu-
larly awful may be an important feature underlying
affective and cognitive responses to health concerns (i.e.,
disease phobia and disease conviction). Overall, the current

123
Cogn Ther Res (2011) 35:566–574
results support the importance given to affective and cog-
nitive dimensions of HC within the extant literature.
Assessment of HC
The MIHT is currently the only known measure that has
separate scales assessing the affective, cognitive, percep-
tual, and behavioral dimensions of HC. However,
researchers have questioned the validity of the perceptual
and behavioral scales of the MIHT, as Olatunji (2008)
suggested that MIHT-absorption has limited theoretical
relevance to health anxiety and Stewart et al. (2008) noted
that MIHT-reassurance fails to assess important safety-
seeking behaviors associated with the disorder. Thus,
limitations of these MIHT scales may have minimized the
contribution of the perceptual and behavioral dimensions in
the prediction of medical utilization and somatic symptoms
in the current study.
Improving upon the assessment of the perceptual and
behavioral dimensions of HC within contemporary self-
report measures (i.e., SHAI and MIHT) may be particularly
important, as the only modest amount of variance
explained in HC-related criteria (i.e., medical utilization
and somatic symptoms) indicates our present understand-
ing of these phenomena is limited. As noted by Stewart
et al. (2008), the assessment of the behavioral dimension
within the MIHT should be broadened to include other
relevant HC behaviors, such as body checking and avoid-
ance. Greater emphasis of the behavioral dimension within
the SHAI seems warranted as well, as it currently only
indirectly assesses behavioral components of the disorder
(e.g., I am not relieved if my doctor tells me there is
nothing wrong).
The assessment of the perceptual dimension of HC
could be improved upon by devoting more item content to
the construct of body vigilance, which represents the ten-
dency to excessively attend to and monitor normal body
sensations (Abramowitz et al. 2002). Body vigilance has
been found to incrementally contribute—beyond the
affective and cognitive dimensions of HC—to the predic-
tion of medical utilization scores and theorists purport that
excessive vigilance to body sensations leads to the dis-
covery of ‘‘new’’ somatic complaints (Abramowitz et al.
2002; Fergus and Valentiner 2010). The SHAI originally
contained three items assessing body vigilance; however,
its scale properties function best when one of these items
are dropped from the measure and the other two items are
subsumed within the illness-likelihood factor (Wheaton
et al. 2010). Whereas the MIHT contains items assessing
perceptions of body sensations (i.e., MIHT-perceptual),
these MIHT items mostly tap body position (e.g., I notice
how clothes feel against my body; When lying in bed at
573
night, I am often aware of my body) rather than body
vigilance per se.
Limitations and Conclusions
Limitations associated with the current study should be
noted. First, the method of assessment (i.e., fixed-order,
self-report) likely inflated the relations among the study
variables. Of note, however, examining latent SHAI-MIHT
relationships allowed for the adjustment of correlated
measurement error, which may be expected when using a
monomethod assessment (Brown 2006). Further, although
the measure chosen to assess medication utilization has
appeared satisfactory across a number of studies, there
exist limited data regarding its psychometric properties.
Similarly, whereas our measure of somatic symptoms is an
often used measure of this construct, an updated version
and other measures of somatic symptoms exist (see Kroenke
2007). Whereas advantages of investigating HC in non-
clinical samples have been noted, the generality of these
findings to clinical populations is not known. Of note, a
non-trivial proportion of the current sample scored in what
may be considered an elevated range. Finally, although
current physical health was assessed, the possibility that
previous physical health influenced observed levels of HC
was not accounted for in the current study.
Limitations notwithstanding, the current results are con-
sistent with conclusions reached by Stewart et al. (2008).
That is, neither the SHAI nor the MIHT appear to be ‘‘stand
alone’’ self-report measures that assess the full domain of
health anxiety. However, both the SHAI and the MIHT have
strengths. Given its relative brevity and the presence of a
cutoff score to determine clinically elevated levels of health
anxiety symptoms (see Rode et al. 2006), the SHAI may be
particularly useful for providing researchers and clinicians
with an overall indication of health anxiety symptomatol-
ogy. The MIHT offers the advantage of having separate
scales that assess the core dimensions believed to underlie
HC (i.e., affective and cognitive dimensions), with the cur-
rent results supporting the utility of both scales. Additional
measures would then seemingly need to be used to provide a
more complete clinical picture. Future research may exam-
ine the validity of reduced-item versions of the SHAI and the
MIHT that contain only the scales that demonstrated utility
in the current study (i.e., SHAI-illness likelihood, MIHT-
alienation, and MIHT-worry). In sum, despite the SHAI and
the MIHT both having relative strengths, a self-report
measure that captures the full health anxiety domain still
seems to be lacking within the extant HC literature. The
identification of such a measure is of great importance, as it
would improve upon the conceptualization, assessment, and
treatment of the disorder.
123
574
References
Abramowitz, J. S., Deacon, B. J., & Valentiner, D. P. (2007a). The
Short Health Anxiety Inventory in an undergraduate sample:
Implications for a cognitive-behavioral model of hypochondri-
asis. Cognitive Therapy and Research, 31, 871–883.
Abramowitz, J. S., & Moore, E. L. (2007). An experimental analysis
of hypochondriasis. Behaviour Research and Therapy, 45,
413–424.
Abramowitz, J. S., Olatunji, B. O., & Deacon, B. J. (2007b). Health
anxiety, hypochondriasis, and the anxiety disorders. Behavior
Therapy, 38, 86–94.
Abramowitz, J. S., Schwartz, S. A., & Whiteside, S. P. (2002). A
contemporary conceptual model of hypochondriasis. Mayo
Clinic Proceedings, 77, 1323–1330.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington DC:
Author.
Bernaards, C. A., & Sijtsma, K. (2000). Influence of imputation and
EM methods on factor analysis when item nonresponse in
questionnaire data is nonignorable. Multivariate Behavioral
Research, 35, 321–364.
Brown, T. A. (2006). Confirmatory factor analysis for applied
research. New York: Guilford Press.
Cheung, G. W., & Rensvold, R. B. (2002). Evaluating goodness-of-fit
indexes for testing measurement invariance. Structural Equation
Modeling, 9, 233–255.
Deacon, B., & Abramowitz, J. S. (2008). Is hypochondriasis related to
obsessive-compulsive disorder, panic disorder, or both? An
empirical evaluation. Journal of Cognitive Psychotherapy: An
International Quarterly, 22, 115–127.
Derogatis, L. R., Lipman, R., Rickels, K., Uhlenhuth, E. H., & Covi,
L. (1974). The Hopkins Symptom Checklist (HSCL): A self-
report symptom inventory. Behavioural Science, 19, 1–15.
Fergus, T. A., & Valentiner, D. P. (2009). Reexamining the domain of
hypochondriasis: Comparing the Illness Attitudes Scale to other
approaches. Journal of Anxiety Disorders, 23, 760–766.
Fergus, T. A., & Valentiner, D. P. (2010). Disease phobia and disease
conviction are separate dimensions underlying hypochondriasis.
Journal of Behavior Therapy and Experimental Psychiatry, 41,
438–444.
Hiller, W., Rief, W., & Fichter, M. M. (2002). Dimensional and
categorical approaches to hypochondrias. Psychological Medi-
cine, 32, 707–718.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in
covariance structure analysis: Conventional criteria versus new
alternatives. Structural Equation Modeling, 6, 1–55.
Jöreskog, K. G., & Sörbom, D. (2003). LISREL (Version 8.54)
[Computer software]. Chicago: Scientific Software Inc.
Kellner, R. (1986). Somatization and hypochondriasis. New York:
Praeger Publishers.
Kroenke, K. (2007). Somatoform disorders and recent diagnostic
controversies. Psychiatric Clinics of North America, 30,
593–619.
Longley, S. L., Broman-Fulks, J. J., Calamari, J. E., Noyes, R., Wade,
M., & Orlando, C. M. (2010). A taxometric study of hypochon-
driasis symptoms. Behavior Therapy, 41, 505–514.
Longley, S. L., Watson, D., & Noyes, R., Jr. (2005). Assessment of
the hypochondriasis domain: The Multidimensional Inventory of
Hypochondriacal Traits (MIHT). Psychological Assessment, 17,
3–14.
123
Cogn Ther Res (2011) 35:566–574
Noyes, R., Jr, Carney, C. P., & Langbehn, D. R. (2004). Specific
phobia of illness: Search for a new subtype. Journal of Anxiety
Disorders, 18, 531–545.
Olatunji, B. O. (2008). New directions in research on health anxiety
and hypochondriasis: Commentary on a timely special series.
Journal of Cognitive Psychotherapy: An International Quarterly,
22, 183–190.
Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S. (2009). Is
hypochondriasis an anxiety disorder? British Journal of Psychi-
atry, 194, 481–482.
Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal
of Psychiatry, 113, 89–93.
Raykov, T., & Penev, S. (1998). Nested structural equation models:
Noncentrality and power of restriction test. Structural Equation
Modeling, 5, 229–246.
Rindskopf, D., & Rose, T. (1988). Some theory and applications of
confirmatory second-order factor analysis. Multivariate Behav-
ioral Research, 23, 51–67.
Rode, S., Salkovskis, P. M., Dowd, H., & Hanna, M. (2006). Health
anxiety levels in chronic pain clinic attenders. Journal of
Psychosomatic Research, 60, 155–161.
Salkovskis, P. M., Rimes, K. A., Warwick, H. M., & Clark, D. M.
(2002). The Health Anxiety Inventory: Development and
validation of scales for the measurement of health anxiety and
hypochondriasis. Psychological Medicine, 32, 843–853.
Satorra, A., & Bentler, P. M. (1994). Corrections to test statistics and
standard errors in covariance structure analysis. In A. von Eye &
C. C. Clogg (Eds.), Latent variable analysis: Applications for
developmental research (pp. 399–419). Thousand Oaks, CA:
Sage.
Satorra, A., & Bentler, P. M. (2001). A scaled difference chi-square
test statistic for moment structure analysis. Psychometrika, 66,
507–514.
Stewart, S. H., Sherry, S. B., Watt, M. C., Grant, V. V., &
Hadjistavropoulos, H. D. (2008). Psychometric evaluation of the
Multidimensional Inventory of Hypochondriacal Traits: Factor
structure and relationship to anxiety sensitivity. Journal of
Cognitive Psychotherapy: An International Quarterly, 22,
97–114.
Stuart, S., & Noyes, R., Jr. (1999). Attachment and interpersonal
communication in somatization. Psychosomatics, 40, 34–43.
van Ginkel, J. R., van der Ark, L. A., & Sijtsma, K. (2007). Multiple
imputation of item scores in test and questionnaire data, and
influence on psychometric results. Multivariate Behavioral
Research, 42, 387–414.
Wang, M., & Russell, S. S. (2005). Measurement equivalence of the
job descriptive index across Chinese and American workers:
Results from confirmatory factor analysis and item response
theory. Educational and Psychological Measurement, 65,
709–732.
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and
validation of brief measures of positive and negative affect: The
PANAS scales. Journal of Personality and Social Psychology,
54, 1063–1070.
Wheaton, M. G., Berman, N. C., Franklin, J. C., & Abramowitz, J. S.
(2010). Health anxiety: Latent structure and associations with
anxiety-related psychological processes in a student sample.
Journal of Psychopathology and Behavioral Assessment, 32,
565–574.