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Journal of Cognitive Psychotherapy: An International Quarterly
Volume 22, Number 2 • 2008
128 ©
2008 Springer Publishing Company
DOI: 10.1891/0889-8391.22.2.128
Specificity of Childhood Learning
Experiences in Relation to Anxiety
Sensitivity and Illness/Injury Sensitivity:
Implications for Health Anxiety and Pain
Margo C. Watt, PhD
Saint Francis Xavier University, Antigonish, and
Dalhousie University, Halifax, NS, Canada
Roisin M. O’Connor, PhD
University of Washington, Seattle
Sherry H. Stewart , PhD
Erin C. Moon , BA
Dalhousie University, Halifax, NS, Canada
Lesley Terry , BA
Saint Francis Xavier University, Antigonish, NS, Canada
Health anxiety refers to the preoccupation with and fear of bodily sensations arising from
catastrophic misinterpretations about the significance of these sensations (Hadjistavropoulos,
Asmundson, & Kowalyk, 2004). Constructs theoretically relevant to the development of both
health anxiety and chronic pain are two of the putative “fundamental fears” identified by Reiss
(1991)—anxiety sensitivity (AS) and illness/injury sensitivity (IS) (Cox, Borger, & Enns, 1999;
Vancleef, Peters, Roelofs, & Asmundson, 2006). The learning history origins of AS have been
examined in a series of studies (Stewart et al., 2001; Watt & Stewart, 2000; Watt, Stewart, &
Cox, 1998); however, no studies have examined the learning history antecedents of IS. The
present retrospective study compared the relative specificity of learning experiences related
to the development of AS and IS in a sample of 192 undergraduates (143 women and 49
men). Structural equation modeling supported nonspecific paths from both anxiety-related
and aches/pains-related childhood learning experiences to AS and a more specific path from
aches/pain-related childhood learning experiences to IS. Results suggest that the developmen-
tal antecedents of IS are more specific to learning experiences around aches and pains, whereas
the developmental origins of AS are more broadly related to learning experiences around
bodily sensations.
Keywords: anxiety sensitivity; illness/injury sensitivity; health anxiety; pain; learning experiences
Learning History and AS Versus IS 129
Health anxiety refers to a continuum of health-related fears and beliefs ranging from no
concern about bodily sensations at one end to extreme fear of and preoccupation with
bodily sensations at the other (Hadjistavropoulos, Asmundson, & Kowalyk, 2004). The
cognitive-behavioral model of health anxiety purports that the key maintaining factor is cata-
strophic misinterpretation of health-relevant information. According to this hypothesis, certain
individuals experience persistent health anxiety because of an enduring tendency to misinterpret
bodily sensations, medical information, and other information regarded as relevant to their
health as evidence that they currently have or are at risk of developing a serious physical illness
(Rode, Salkovskis, & Jack, 2001).
Some researchers have suggested a role for health anxiety in chronic pain (e.g., Rode et al.,
2001); however, the prevalence of health anxiety among chronic pain patients remains in need of
further investigation (Hadjistavropoulos, Owens, Hadjistavropoulos, & Asmundson, 2001). One
recent study of 161 chronic pain patients reported conservative estimates of current prevalence
rates as being 51% for significant health anxiety, including 37% for full-blown hypochondriasis
(Rode, Salkovskis, Dowd, & Hanna, 2006). A cognitive-behavioral model, similar to that pro-
posed for health anxiety, has been proposed for chronic pain. Specifically, this model proposes
that chronic pain patients have an enduring tendency to misinterpret pain sensations as a sign
that they may be vulnerable to or have already sustained serious physical damage (Rode et al.,
2001). Rode et al. suggested that three types of catastrophizing appraisals may be especially
important in chronic pain that has a prominent health anxiety component: (a) pain-focused con-
sequences (“This pain will come to dominate my life”), (b) damage-focused consequences (“This
pain is nature’s way of telling me to be extremely careful”), and (c) disease-focused causes (“This
pain is a sign of something really serious”).
To better understand the relationship between health anxiety and chronic pain, it may be
useful to consider their potential common derivation from the three fundamental sensitivities
outlined by Reiss and McNally (1985): anxiety sensitivity (AS), illness/injury sensitivity (IS),
and negative evaluation sensitivity (NES). These three dimensions are considered fundamental
because they represent the potential to fear inherently aversive stimuli or events and because other
common fears are believed to result from these sensitivities (Reiss, 1991). For example, AS may
result in the development of panic attacks or panic disorder (Schmidt, Lerew, & Jackson, 1997), IS
may contribute to the development of health anxiety–related conditions including chronic pain
(Carleton, Park, & Asmundson, 2006), and NES may result in social phobia (Wells et al., 1995).
Research indicates that AS is comprised of three empirically distinct but intercorrelated, lower-
order dimensions: Physical Concerns (fear of negative physical consequences of anxiety-related somatic
sensations), Psychological Concerns (fear of negative psychological consequences of anxiety-related
cognitive sensations), and Social Concerns (fear of negative social consequences of publicly observ-
able anxiety sensations) (Stewart, Taylor, & Baker, 1997; Zinbarg, Mohlman, & Hong, 1999). Studies
have found that elevations in these AS dimensions show specificity for different forms of anxiety-
related psychopathology, such as Physical Concerns with panic disorder, Psychological Concerns
with obsessive-compulsive disorder, and Social Concerns with social phobia (see Cox, Borger, &
Enns, 1999). AS-Physical Concerns has also been linked to hypochondriasis (see Cox et al., 1999).
Taylor (1993) developed the 11-item Illness/Injury Sensitivity Index (ISI) as a specific mea-
sure of the fear and catastrophic appraisal of illness and/or injury. It included six items pertaining
to the fear of illness and five items referring to the fear of injury. Taylor (1993) conducted a prin-
cipal components analysis on the ISI items and items from two established instruments of the
other fundamental sensitivities (i.e., the Anxiety Sensitivity Index [ASI; Peterson & Reiss, 1992]
to measure AS and the Fear of Negative Evaluation scale [FNE; Leary, 1983] to measure NES). He
found support for the factorial distinctiveness of the three fundamental fears. Taylor also found
that each fundamental fear was uniquely related to certain common fears: AS to agoraphobia, IS
to blood-injury phobia, and NES to social phobia.
130 Watt et al.
An investigation of the psychometric properties of the ISI conducted by Carleton, Asmund-
son, and Taylor (2005) revealed a two-factor solution comprising items related to Fear of Illness
(factor 1) and Fear of Injury (factor 2), respectively. This two-component solution indicated a
factorial distinction between injury and illness sensitivities, which contrasted with the view of IS
as a singular fundamental fear (Reiss, 1991; Taylor, 1993). Convergent validity was found between
each ISI subscale and the Physical Concerns subscale of the ASI (Peterson & Reiss, 1992). This
prompted the authors to speculate that the relationship between the ISI and ASI might be one of
amplification, with fear of somatic sensations mediating fear responses associated with the fear
of physical harm (whether from injury or illness). Carleton et al. (2005) concluded that IS might
be better conceptualized as Fear of Physical Harm, with injury and illness fears being related but
distinct subcomponents of this fear.
Additional support for the two-factor solution for the ISI was provided in a subsequent
study (Carleton et al., 2006). This study also found significant correlations between both ISI sub-
scales and the Physical Concerns subscale of the ASI. In addition, the Fear of Illness subscale was
found to have a strong association with the fear of illness and pain factor of the Illness Attitudes
Scale (Kellner, 1986), a widely used measure of health anxiety–related fears, beliefs, and attitudes.
Both Fear of Illness and Fear of Injury had strong positive correlations ( r = .70 and r = .65, respec-
tively) with the Fearful Appraisals of Pain subscale of the 20-item Pain Anxiety Symptoms Scale
(PASS-20; McCracken & Dinghra, 2002).
Most pain research has focused on AS as a relevant fundamental fear. A number of studies
(e.g., Asmundson & Norton, 1995; Asmundson, Norton, & Veloso, 1999; Asmundson, Wright, &
Hadjistavropoulos, 2000) have found high levels of AS to be associated with more overall fear of
pain and with each of the core components of fear of pain as measured on the original 40-item
PASS (McCracken, Zayfert, & Gross, 1992) or the PASS-20 (McCracken & Dinghra, 2002): cogni-
tive anxiety, fearful appraisals of pain, pain-related escape/avoidance behavior, and physiological
anxiety related to pain. It has been suggested that AS is one of the factors that mediates fear of
pain and ultimately contributes to the etiology of chronic pain (see Asmundson et al., 2005).
While AS has garnered most of the research attention, recently it has been suggested that IS
may be more fundamental to the maintenance and exacerbation of health conditions like chronic
pain (Vancleef, Peters, Roelofs, & Asmundson, 2006). In a sample of university students, Vancleef
et al. (2006) found that IS and AS (but not FNE) significantly predicted pain catastrophizing
and fear of pain as measured by the PASS (McCracken et al., 1992). While AS was a significantly
stronger predictor of physiological anxiety than IS, IS was a significantly stronger predictor of
escape/avoidance behavior than AS. IS also proved to be the only predictor of anticipatory fear for
impending pain stimuli (i.e., an ischemic pain test, electrical stimulation, and heat pain stimula-
tion), leading the authors to conclude that IS represents a specific sensitivity to the threat of pain
and the fear of potential consequences that may go along with injury and illness. Using the same
self-report measures as Vancleef et al. (2006), Watt, Stewart, and Moon (2007) found that AS-
Physical Concerns was the strongest and most significant predictor of all PASS-20 subscales over
and above the collective contribution of the IS dimensions (Illness and Injury Sensitivities).
Lilienfeld, Turner, and Jacob (1993) approached their examination of fundamental fears
from a hierarchical perspective, proposing that AS, IS, and NES are lower-order factors nested
within the higher-order factor of trait anxiety. This model was extended by Keogh and Asmund-
son (2004), who suggested that IS may act as a higher-order factor of pain-related constructs,
including fear of pain. Vancleef et al.’s (2006) study supported this model and raised the addi-
tional possibility that IS was, perhaps, a lower-order component of another fundamental fear,
namely, AS. In other words, the fear of illness or injury may stem from a more general fear of
arousal-related sensations.
Rode et al. (2006) proposed that individual differences in anxiety-related responses to pain
sensations are determined in part by biology (i.e., evolutionary heritage) but also could be
Learning History and AS Versus IS 131
determined through personal learning histories. The learning history origins of AS have been
examined in a series of three studies (Stewart et al., 2001; Watt & Stewart, 1998; Watt, Stewart, &
Cox, 1998). In all three studies, results indicated that elevated AS levels were associated with
increased instrumental (i.e., reinforcement for sick-role behavior related to bodily symptoms)
and vicarious (i.e., parental modeling of sick-role behavior or verbal transmission of fears of
bodily symptoms) learning experiences. Moreover, the learning experiences contributing to
AS concerned learning to fear not only anxiety sensations (e.g., rapid heartbeat) but also other
bodily sensations (e.g., pain) more generally. By contrast, little is known about the developmental
antecedents of IS.
To summarize, research suggests that the fundamental fears of AS and IS but not NES appear
to be central to health anxiety- and pain-related conditions. Whereas we know something about
the developmental antecedents of AS (e.g., Watt et al., 1998), we know nothing about the devel-
opmental origins of IS. Understanding the role of learning history in the development of these
two fundamental fears, AS and IS, could be an important step in enabling us to identify who is at
risk for health anxiety- and pain-related psychopathology.
The present study sought to compare the relative specificity of learning experiences related
to the development of both AS and IS in a sample of undergraduates. Our hypothesized model is
displayed in Figure 1. Given the results of our previous studies (e.g., Watt et al., 1998), we predicted
that AS would be associated with childhood learning experiences related to somatic sensations in
general (i.e., both anxiety and aches/pains sensations). Given that IS may be a lower-order compo-
nent of the higher-order AS (Vancleef et al., 2006), it was predicted that IS would be associated with
more specific childhood learning experiences, particularly those related to aches and pains.
M ETHOD
Participants
A total of 192 (143 women and 49 men) undergraduate students at two eastern Canadian uni-
versities volunteered for the study. Participants were compensated for their time and effort with
partial course credit. Participants’ mean age was 19.4 years ( SD = 3.5). The vast majority of the
Learning
History
Anxiety
Learning
History
Pain
Anxiety
Sensitivity
Illness/Injury
Sensitivity
FIGURE 1. Proposed model indicating hypothesized structural paths between variables of
interest.
132 Watt et al.
participants were White (93%), and the median family annual income fell in the range of 51,000
to 75,000 Canadian dollars. Three participants did not respond to one item on our primary out-
come measure. Missing values replacement was conducted by imputing the subject’s mean value
for the particular scale, prior to calculation of overall scale scores.
Measures
Demographics Questionnaire. An author-constructed demographics measure assessed par-
ticipants’ age, sex, family income, and ethnicity.
Learning History Questionnaire—IV. For the purposes of the present study, we used a
revised version of the Learning History Questionnaire (LHQ) previously modified by Ehlers
(1993) to assess learning experiences related to anxiety symptoms. The original questionnaire on
which Ehlers’s (1993) modification was based was developed by Whitehead, Busch, Heller, and
Costa (1986) to investigate the learning history origins of menstrual distress. The revised LHQ
used in the present study (LHQ-IV) consisted of six subscales, four of which were relevant to the
present investigation.
The first subscale of the revised LHQ, Experience/Anxiety, is a composite scale of partici-
pants’ reported frequency of anxiety experiences prior to age 17 years (Personal Anxiety item)
multiplied by the mean frequency of parental encouragement of sick-role behavior when par-
ticipants had anxiety-related symptoms as children (Encourage/Anxiety scale, 22 items). Partici-
pants were asked to indicate their frequency of experiencing a list of symptoms associated with
anxiety before the age of 17 years (e.g., dizziness, shortness of breath, or strong nausea) (Personal
Anxiety). If they answered affirmatively to these items, they were also asked several questions
about parental encouragement of sick-role behavior in response to these symptoms (Encour-
age/Anxiety). Included on this scale were 10 questions related to negative reinforcement (e.g.,
“Were you allowed to stay home from school when experiencing these symptoms?”) and positive
reinforcement of sick-role behavior (e.g., “Did you receive special care?”), eight questions about
parents’ verbal transmission of the idea that anxiety symptoms are dangerous (e.g., “Did your
parents warn you of the danger of such symptoms?”), and four questions related to parental dis-
couragement or punishment of sick-role behavior (e.g., “Were you made to feel responsible for
having caused the symptoms?”). For consistency with instrumental learning theory predictions,
the four punishment items were reverse scored.
The second subscale, Observation/Anxiety, is a composite scale of participants’ reported
frequency of parental reporting of anxiety experiences prior to the participant reaching age 17
years (Parental Anxiety item) multiplied by the mean frequency of parental modeling of sick-role
behavior when parents suffered these symptoms (Modeling/Anxiety scale, 20 items). Participants
were first asked, “Did your father or mother (or other with whom you lived) suffer from symptoms
such as racing heartbeat, dizziness, shortness of breath, or strong nausea?” (Parental Anxiety). If
participants responded affirmatively to the Parental Anxiety item, they were then asked to respond
to questions concerning parental modeling of sick-role behavior when suffering these symptoms
(Model/Anxiety). These questions resembled the items on the Encourage/Anxiety scale described
previously, including eight positive and negative reinforcement items, eight verbal transmission
items, and four punishment items relating to the observed consequences of parental anxiety
symptom displays and complaints. The four punishment items were again reverse scored.
The third subscale, Experience/Pain, is similar to the Experience/Anxiety scale and represents
a composite of participants’ reported frequency of pain experiences prior to age 17 years (Per-
sonal Pain) multiplied by the mean frequency of parental encouragement of sick-role behavior
when participants had pain-related symptoms (e.g., headaches, stomachaches, ear infections,
or muscle cramps) as children (Encourage/Pain scale, 22 items). The fourth subscale, Observa-
tion/Pain, resembles the Observation/Anxiety scale and represents a composite of participants’
Learning History and AS Versus IS 133
reported frequency of parental pain experiences before the participant reached age 17 years
(Parental Pain) multiplied by the mean frequency of parental modeling of sick-role behavior
when parents suffered these symptoms (e.g., headaches, stomachaches, ear infections, or muscle
cramps) (Modeling/Pain scale, 20 items). Participants responded to all LHQ questions on a rela-
tive frequency scale ranging from 0 to 3, where 0 = “never,” 1 = “seldom” (once or twice a year),
2 = “occasionally” (three to six times a year), and 3 = “often” (more than six times a year).
Internal consistencies (Cronbach’s alphas) for the multi-item components of the four LHQ-
IV scales were calculated on the basis of the responses of the total student sample ( N = 192).
Internal consistency estimates were .87 for the Encourage/Pain scale, .92 for the Modeling/Pain
scale, .93 for the Encourage/Anxiety scale, and .96 for the Modeling/Anxiety scale.
1
ASI. The ASI is a 16-item self-report questionnaire designed to assess the amount of fear
experienced in response to anxiety-related sensations due to beliefs that these sensations have
catastrophic consequences. For each item, participants are asked to indicate their degree of agree-
ment on a Likert scale ranging from very little (scored as 0) to very much (scored as 4). All items
are summed for a total score ranging between 0 and 64. The ASI has good internal consistency,
test–retest reliability, and construct- and criterion-related validity (Peterson & Reiss, 1992).
The ASI was scored according to its three lower-order subscales (Physical, Psychological, and
Social Concerns) using the scoring system recommended by Zinbarg et al. (1999). The Physical
Concerns subscale included eight items (items 3, 4, 6, 8, 9, 10, 11, and 14; e.g., “It scares me when I
feel ‘shaky’ [trembling]”). The Psychological Concerns subscale included four items (items 2, 12,
15, and 16; e.g., “When I cannot keep my mind on a task, I worry that I might be going crazy”).
The Social Concerns subscale included the remaining four items (items 1, 5, 7, and 13; e.g., “It
embarrasses me when my stomach growls”). Given the differing number of items, ASI subscales
were scored as item means (possible range = 0–4). Internal reliability of the three ASI subscales
in the present study ranged from .44 for Social Concerns to .75 for Psychological Concerns and
.87 for Physical Concerns as determined by Cronbach’s alpha. These reliabilities are consistent
with the findings of other studies (e.g., Watt & Stewart, 2003).
ISI. The ISI is an 11-item measure of illness/injury sensitivity. Items are rated on a 5-point
Likert scale ranging from 0 ( agree very little ) to 4 ( agree very much ). Research (Carleton et al.,
2005, 2006) supports the existence of two factors: the Illness Sensitivity subscale, which includes
six items (items 3, 4, 6, 8, 9, and 10; e.g., “I worry about becoming physically ill”), and the Injury
Sensitivity subscale, which includes five items (items 1, 2, 5, 7, and 11; e.g., “I am frightened of
being injured”). These factors were scored as separate subscales in the present study. The ISI pos-
sesses adequate psychometric properties and has been shown to be distinct from other measures
of fundamental fears, such as the ASI and FNE (see Carleton et al., 2005, 2006; Taylor, 1993). The
two subscales showed good internal consistency in the present sample with internal reliabilities
of .87 each as determined by Cronbach’s alpha. Given the differing number of items, ISI subscales
were scored as item means (possible range = 0–4).
R ESULTS
Summary Statistics
Table 1 displays the means, standard deviations, and medians for the variables of interest in the
present study. These means compare well with the findings of previous studies (e.g., Carleton
et al., 2006; Watt & Stewart, 2003).
The sample means, medians, and standard deviations on the four composite LHQ-IV scales
also are presented in Table 1. Student participants tended to report more childhood experiences
related to pain than anxiety and scored higher on learning history scales tapping instrumental
learning versus vicarious learning experiences.
134 Watt et al.
TABLE 1. DESCRIPTIVE STATISTICS ON DEMOGRAPHICS, ANXIETY AND ILLNESS/INJURY SENSITIVITY,
AND LEARNING HISTORY QUESTIONNAIRE SCORES (N = 192)
M(SD) Median
Demographic measures
Age (in years) 19.45 (3.45) 18.00
Gender (% female) 75%
Anxiety and Illness/Injury Sensitivity measures (range)
ASI (0–64) 16.89 (9.5) 15.00
Physical Concerns (0–4) 0.98 (0.75) 0.88
Psychological Concerns (0–4) 0.62 (0.67) 0.50
Social Concerns (0–4) 1.64 (0.65) 1.50
ISI (0–44) 17.36 (9.79) 16.50
Illness Sensitivity (0–4) 1.67 (0.92) 1.58
Injury Sensitivity (0–4) 1.47 (0.98) 1.40
LHQ-IV Scale scores (range)
Experience/Anxiety (0–9) 0.83 (1.09) 0.50
Personal Anxiety (0–3) 1.09 (1.03) 1.00
Encourage/Anxiety (0–3) 0.47 (0.49) 0.41
Observation/Anxiety (0–9) 0.47 (1.06) 0.00
Parental Anxiety (0–3) 0.55 (0.91) 0.00
Modeling/Anxiety (0–3) 0.27 (0.50) 0.00
Experience/Pain (0–9) 1.87 (1.32) 1.61
Personal Pain (0–3) 2.02 (0.87) 2.00
Encourage/Pain (0–3) 0.88 (0.43) 0.91
Observation/Pain (0–9) 1.31 (1.33) 0.90
Parental Pain (0–3) 1.59 (1.01) 2.00
Modeling/Pain (0–3) 0.64 (0.49) 0.60
Note. ASI = Anxiety Sensitivity Index; ISI = Illness/Injury Sensitivity Index;
LHQ-IV = Learning History Questionnaire–IV.
The raw variables were tested for significant skewness and kurtosis ( p < .05; Tabachnick &
Fidell, 2001). Results revealed that all the composite LHQ-IV variables (Experience/Anxiety,
Observation/Anxiety, Experience/Pain, Observation/Pain) were significantly positively skewed,
which is consistent with previous findings (compare Watt et al., 1998), and were significantly
kurtotic. In addition, the ASI-Physical Concerns and ASI-Psychological Concerns variables were
significantly positively skewed and kurtotic. According to Tabachnick and Fidell’s (2001) recom-
mendations for positively skewed data, prior to further analyses, square root transformations
were performed on these variables and brought skewness and kurtosis within acceptable limits.
All subsequent results reported here used the transformed data.
Bivariate Correlations
Bivariate correlations were computed between scores on the four LHQ-IV composite scales
(square root–transformed data) and the ASI (square root–transformed scores for Physical and
Psychological Concerns) and ISI subscales. The resultant intercorrelation matrix is shown in
Table 2. Scores on the four LHQ-IV scales were positively intercorrelated, with two of the six inter-
scale correlations proving statistically significant following Bonferroni correction (see Table 2).
TABLE 2. PEARSON CORRELATIONS BETWEEN LHQ-IV SCALES AND ASI AND ISI SUBSCALE SCORES IN THE TOTAL SAMPLE
OF STUDENTS (N = 192)
123456789
(1) Experience/Anxiety — .32**** .20** .14 .29**** .20*** .18** .11 .09
(2) Observation/Anxiety — .19** .17* .15* .18** .09 .09 .08
(3) Experience/Pain — .37**** .27**** .21*** .16* .16* .20**
(4) Observation/Pain — .18** .09 .07 .15* .13
(5) ASI-Physical — .60**** .47**** .42**** .52****
(6) ASI-Psychological — .38**** .33**** .33****
(7) ASI-Social — .28**** .36****
(8) ISI-Injury — .78****
(9) ISI-Illness —
Note. Correlations in bold are significant at the Bonferroni-adjusted alpha level of .001 (.05/36) (one tailed); ASI = Anxiety Sensitivity
Index; ISI = Illness/Injury Sensitivity Index. Scores on the four Learning History Questionnaire– IV composite scales and on the ASI-
Physical and Psychological Concerns scales were square root transformed to reduce skewness prior to the calculation of correlation
coefficients.
*p < .05. **p < .01. ***p < .005. ****p < .001.
136 Watt et al.
Shared variance between scales ranged from 2% (Experience/Anxiety with Observation/Pain)
to 14% (Experience/Anxiety with Observation/Anxiety; and Experience/Pain with Observation/
Pain). The average interscale correlation was r = .23 ( p < .001), indicating an average shared vari-
ance between LHQ-IV scales of about 5%.
Both the Experience/Anxiety and the Experience/Pain scale correlated significantly and
positively with AS-Physical Concerns ( r = .29, p < .001, and r = .27, p < .001, respectively). Both
the Experience/Pain and the Observation/Pain scale correlated positively with Injury Sensitiv-
ity ( r = .16, p < .05, and r = .15, p < .05, respectively); Experience/Pain also correlated positively
with Illness Sensitivity ( r = .20, p < .01). As expected, ASI and ISI subscales were significantly
and positively correlated with each other with shared variance between subscales ranging from
7% (AS-Social Concerns and IS-Injury Sensitivity) to 25% (AS-Physical Concerns and IS-Illness
Sensitivity) (see Table 2).
Structural Equation Modeling
Consistent with the recommendations of Anderson and Gerbing (1988) for evaluating hybrid
models, we used a two-step approach to test the hypotheses. First, the measurement model was
tested, and, second, the structural (path-analytic) model was tested. Four latent factors were
specified, including (a) Learning History Anxiety (indicated by participants’ personal learning
experience with anxiety [Experience/Anxiety] and parental modeling of anxiety [Observation/
Anxiety]), (b) Learning History Pain (indicated by participants’ personal learning experience
with aches/pain [Experience/Pain] and parental modeling of aches/pain [Observation/Pain]),
(c) Anxiety Sensitivity (indicated by ASI-Physical Concerns, ASI-Psychological Concerns, and
ASI-Social Concerns), and (d) Illness/Injury Sensitivity (indicated by ISI-Illness Sensitivity
and ISI-Injury Sensitivity). To evaluate the measurement model, a fully saturated covariance
structure was used such that covariances were freely estimated between all four latent factors.
The structural, path-analytic model included two exogenous latent factors (Learning History
Anxiety and Learning History Pain) and two endogenous latent factors (Anxiety Sensitivity and
Illness/Injury Sensitivity). In this hybrid model, we simultaneously tested the unique influence
of Learning History Anxiety on Anxiety Sensitivity and the influence of Learning History Pain
on Anxiety Sensitivity and Illness/Injury Sensitivity.
The models were conducted with Mplus Version 3.01 (Muthén & Muthén, 2004) and estimated
from covariance matrices using a maximum-likelihood estimation procedure. As recommended by
Byrne (2001) and Kline (1998), model goodness of fit was evaluated with multiple criteria using
omnibus chi-square tests, Tucker-Lewis Index (TLI; Tucker & Lewis, 1973), the Comparative Fit
Index (CFI; Bentler, 1990), the root mean square error of approximation (RMSEA; Steiger, 1990),
and the standardized root mean square residual (SRMR; Bentler, 1995). Based on Hu and Bentler’s
(1999) criteria, the CFI and TLI should be greater than .95, the RMSEA less than .06, and the
SRMR less than .08. In addition, a χ
2 / df ratio of 3.0 or less is considered to be good (Kline, 1998).
Measurement Model. Evaluation of the measurement model supported the underlying factor
structure of our model. Examination of the fit indices suggested that the measurement model
provided a good fit to the observed data (χ
2 = 13.52, df = 21, p = .89; TLI = 1.03; CFI = 1.00;
RMSEA = .00 [90% confidence interval = .00–.03]; SRMR = .02; χ
2 / df = .64). Goodness of fit
of the measurement model was further supported by the substantial (standardized loadings
> .32; Comrey & Lee, 1992; Tabachnick & Fidell, 2001) and significant loadings (all p s < .01)
of all indicators on their respective factors (see Figure 1). Of note, examination of the covariance
structure revealed that while the correlation between Learning History Anxiety and Illness/Injury
Sensitivity was not significant ( r = .15, p = .15), all other correlations were significant ( r s ranged
from .28 [Learning History Pain and Illness/Injury Sensitivity] to .60 [Anxiety Sensitivity and
Illness/Injury Sensitivity], all p s < .01).
Learning History and AS Versus IS 137
Structural Model. The overall fit of the hybrid model to the data was good (χ
2
= 13.59, df =
22, p = .92; TLI = 1.03; CFI = 1.00; RMSEA = .00 [90% confidence interval = .00 to .02]; SRMR
= .02; χ
2 / df = .62). Furthermore, a nested chi-square difference test comparing the omnibus chi-
square of the measurement model with the hybrid model (χ
2 [1] = .07, p > .05) indicated that the
addition of the hypothesized paths did not result in a decrement in model fit and thus that the
structural component of the model was also providing adequate fit to the data.
Examination of the path coefficients (see Figure 2) revealed that Learning History Anxiety
was a significant predictor of Anxiety Sensitivity (unstandardized B = .30, SE = .13; p < .05)
and that Learning History Pain was a marginally significant (unstandardized B = .24, SE = .13;
p = .06) predictor of Anxiety Sensitivity and a significant predictor of Illness/Injury Sensitivity
(unstandardized B = .64, SE = .26; p < .05). Overall, this model accounted for 25% of the variance
in Anxiety Sensitivity and 8% of the variance in Illness/Injury Sensitivity.
Exp/Anx Obs/Anx
Exp/Pain Obs/Pain
Social
Psychol.
Physical
InjuryIllness
Learning
History
Anxiety
Learning
History
Pain
Anxiety
Sensitivity
Illness/ Injury
Sensitivity
.55
.54
.66
.89
.48.67
.28**
.26*
.33**
.70
.56
.23.77
.75
.92
.35.07
.80.97
.50
.75.50
.74
.45
.48
FIGURE 2. Hybrid model with standardized solution. The hypothesized association between
Anxiety Sensitivity and Illness/Injury Sensitivity is examined by including a correlation between
the disturbance terms of these two endogenous variables. Correlation of the disturbances rather
than the variables themselves is necessary, as endogenous variables do not contain variance.
The variance of endogenous variables is partitioned into that accounted for by the exogenous
variables (path coefficients) and unmeasured variance (disturbance terms). Accordingly, the
correlation between disturbances can be thought of as a partial correlation. See Byrne (2001)
and Kline (1998). Exp/Anx = Experience/Anxiety; Obs/Anx = Observation/Anxiety; Exp/Pain =
Experience/Pain; Obs/Pain = Observation/Pain; Physical = ASI-Physical Concerns; ASI-Psychol. =
ASI-Psychological Concerns; ASI-Social = ASI-Social Concerns; Illness = ISI-Illness Sensitivity;
Injury = ISI-Injury Sensitivity. *p = .06. **p < .05.
138 Watt et al.
D ISCUSSION
The present study sought to examine the specificity of childhood learning experiences related
to the development of AS and IS, which are two of the three fundamental sensitivities proposed
by Reiss (1991) that have been theorized to contribute to the development of anxiety and other
disorders characterized by fear of somatic sensations (e.g., hypochondriasis, chronic pain). Con-
sistent with hypotheses, results indicated that the development of both AS and IS is related to
retrospectively reported learning experiences in childhood and adolescence. Consistent with the
findings of our previous studies (Stewart et al., 2001; Watt & Stewart, 2000; Watt et al., 1998),
learning experiences implicated in the development of AS involved anxiety-related bodily sensa-
tions but also, albeit to a lesser extent, parental reinforcement/modeling of sick-role behavior
related to somatic sensations in general (e.g., aches and pains). The marginal significance of
this latter finding may be attributable to the present inclusion of IS, which was not part of our
previous studies but was highly correlated with AS and associated with pain-related learning
experiences in the current study. Overall, the present findings support our earlier contention that
the origins of heightened AS appear to lie in learning to catastrophize the meaning of somatic
sensations in general rather than anxiety-related sensations in particular.
In contrast to the learning history origins of AS, the development of IS appears linked to
parental modeling and reinforcement of sick-role behavior related to aches and pains more specifi-
cally. This finding appears consistent with the proposition that fear of illness or injury (IS) may be
a lower-order factor of fear of somatic sensations in general (AS) (Vancleef et al., 2006). Accepting
Cattell’s (1978) suggestion that each factor represents a distinct set of causal mechanisms, this find-
ing implies that more than one mechanism underlies fear of arousal-related bodily sensations—a
general mechanism (corresponding to the higher-order factor of AS) and more specific mechanisms
contributing to the development of fear of illness and injury (corresponding to the lower-order fac-
tor of IS). Understanding this relationship between AS and IS may facilitate efforts to disentangle
the relative influences of the general and specific mechanisms on the development, course, and
treatment of health anxiety–related conditions, such as hypochondriasis and chronic pain.
Participants in the present study reported more childhood learning experiences related to
pain than anxiety. Anxiety disorders are among the most prevalent forms of childhood psycho-
pathology, affecting approximately 20% of children and adolescents at some point in their lives
(Morris & March, 2004). Pain also is a common childhood experience. Surveys have found that
approximately 50% of youth report pain experiences within the previous 3 months (Perquin et al.,
2000). These statistics suggest that our participants may have been responding accurately about
their relatively greater experiences with pain than anxiety in childhood. However, it is also possible
that our participants reported more childhood experiences of pain because these pain experiences
were more salient (e.g., more intense) than anxiety experiences and therefore more memorable.
Future research should examine whether increased frequency and/or salience explain the greater
memory for pain versus anxiety experiences in childhood. The influence of social desirability on
reporting of childhood learning experiences might warrant investigation as well. For example,
it may be more socially acceptable to report having had pain than to report having had anxiety
experiences in childhood, particularly for men. Although gender differences were not examined in
the present study, it would be interesting to investigate whether men or women would recall (or at
least report) more childhood learning experiences related to either anxiety or pain.
The small sample size in the present study precluded testing additional and more specific
constructs within the present structural equation modeling. Thus, one direction for future
research is the examination of potential specificity in the relationships of various learning expe-
riences related to pain and anxiety with particular AS and IS lower-order dimensions. Previous
research (e.g., MacPherson, Stewart, & McWilliams, 2001; Watt & Stewart, 2003) has found that
exposure to parental loss of control experiences due to drinking has a specific association with
Learning History and AS Versus IS 139
AS-Psychological (vs. Physical or Social) Concerns. Other research suggests that the development
of AS-Physical Concerns in particular should correspond to learning history events and situations
that typically produce a high degree of bodily arousal and behavioral action (e.g., intense pain)
(see Zvolensky, Goodie, McNeil, Sperry, & Sorrell, 2001). It is interesting to note that, consistent
with this speculation, the bivariate correlations in the present study indicated relations between
instrumental learning around both anxiety and pain and AS-Physical Concerns in particular.
Results of the present study must be considered in light of certain limitations. One potential
limitation is the retrospective design. Retrospective reports have been criticized as being vulner-
able to distortions because of selective memory of past events, demand characteristics of the
study itself, and the influence of current attitudes, behaviors, and experiences. For example, given
the prevalence of current pain in some adolescent samples (Perquin et al., 2000), it is possible that
participants’ current pain experiences influenced their retrospective recall of pain experiences
in childhood. Future research would benefit from the collection of information on participants’
current pain, personal and family history of chronic pain, serious injury or illness experiences,
and psychiatric conditions. In addition, this research should be supplemented with longitudinal
research on the influences of certain childhood learning experiences to the development of the
fundamental fears in children and adolescents.
Ecological validity is a second limitation of the present study. The models were examined in
a university sample, which may limit generalizability of the findings to clinical samples such as
hypochondriasis or chronic pain patients. Use of a healthy population, however, ensured a broad
range of values for both the predictor and the criterion variables that may not be the case in
clinical samples. Replication of the present findings with appropriate clinical samples could serve
to inform prevention approaches for these health conditions. For example, understanding the
learning pathways to hypochondriasis and chronic pain would permit targeting at-risk individu-
als (i.e., high in AS and/or IS and/or those with certain childhood learning histories).
A third limitation of the present study was our failure to include the health outcome mea-
sures of interest (e.g., measures of health anxiety). Previous research (e.g., Watt & Stewart, 2000)
has demonstrated that AS acts as a mediator in the relationship between childhood learning
experiences around somatic sensations and elevated hypochondriacal concerns in young adult-
hood. Future research could investigate the potential mediating effects of AS and IS in bridging
expected relations of learning history to various health anxiety–relevant outcomes.
Hypochondriasis and chronic pain share the commonalities of fear related to somatic sensa-
tions, catastrophizing about the consequences of those sensations, and safety-seeking behaviors
(e.g., avoidance, reassurance seeking) in response to the sensations. Rode et al. (2006) have sug-
gested that these commonalities are both biologically (evolutionary heritage) and psychologically
prepared (personal learning histories). The present study sought to investigate how personal
learning histories were associated with two known risk factors for health anxiety and pain (i.e.,
AS and IS). Findings of the present study suggest that the developmental antecedents of IS are
more specific to learning experiences around aches and pains, whereas the developmental origins
of AS are more broadly related to learning experiences around bodily sensations. This pattern of
results seems to fit with the hierarchical model proposed to account for the relationship between
AS and IS with IS being a lower-order and more basic fear than AS (Vancleef et al., 2006).
Findings of the present study have implications for the prevention and treatment of both
health anxiety- and pain-related disorders. Given that cognitive and behavioral mechanisms are
involved in the development of AS and IS, these same mechanisms can be useful in countering
these fundamental fears to achieve effects on associated health anxiety–related conditions. Watt and
colleagues (Watt, Stewart, Conrod, & Schmidt, 2007; Watt, Stewart, Lefaivre, & Uman, 2006) have
demonstrated that targeting high AS levels via a brief cognitive-behavioral intervention is an effec-
tive approach to reduce pain-related anxiety in high-risk populations. Taking a similar approach to
reducing IS levels might yield similarly positive outcomes with pain-related behavior.
140 Watt et al.
N OTE
1 . We were able to validate the accounts of 43 students by having their parents fill out comparable ver-
sions of the LHQ-IV. Parents were asked to report on their adult child’s frequency of symptoms as children,
their own (parental) frequency of symptoms, and their responses to their child’s and their own symptoms
when their child was growing up. Validity checks in a previous study (Watt et al., 1998) revealed significant
positive correlations between students and parents on the same Experience/Anxiety and Observation/
Anxiety scales used in the LHQ-IV. In the present study, a validity check was performed between the
LHQ-IV pain-related scales of the 43 student–parent pairs. Testing revealed that the two composite
LHQ-IV variables (Experience/Pain and Observation/Pain) were significantly positively skewed and kurtotic
for both students and parents. Following Tabachnick and Fidell’s (2001) recommendations for positively
skewed data, square root transformations were performed on these variables. This brought skewness and
kurtosis within acceptable limits. The transformed data were used in the analyses. The correlation between
parents’ and adult children’s responses to the Experience/Pain scale was statistically significant ( r = .35,
p < .01; one-tailed test), and the positive correlation between parents’ and adult children’s responses on the
Observation/Pain scale approached significance ( r = .21, p < .09; one-tailed test).
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Correspondence regarding this article should be directed to Margo C. Watt, PhD, Department of Psychology,
Saint Francis Xavier University, Antigonish, NS, Canada, B2G 2W5. E-mail: mwatt@stfx.ca
