DEPRESSION AND ANXIETY 00:1–13 (2012)

Research Article
A CLINICIAN-ADMINISTERED SEVERITY RATING SCALE
FOR ILLNESS ANXIETY: DEVELOPMENT, RELIABILITY,
AND VALIDITY OF THE H-YBOCS-M
Natalia A. Skritskaya, Ph.D.,1 ∗ Amanda R. Carson-Wong, M.A.,2 James R. Moeller, Ph.D.,3 Sa Shen, Ph.D.,3
Arthur J. Barsky, M.D.,4,5 and Brian A. Fallon, M.D., M.P.H.3,6

Background: Clinician-administered measures to assess severity of illness anx-

iety and response to treatment are few. The authors evaluated a modified ver-
sion of the hypochondriasis-Y-BOCS (H-YBOCS-M), a 19-item, semistructured,
clinician-administered instrument designed to rate severity of illness-related
thoughts, behaviors, and avoidance. Methods: The scale was administered to
195 treatment-seeking adults with DSM-IV hypochondriasis. Test–retest relia-
bility was assessed in a subsample of 20 patients. Interrater reliability was assessed
by 27 interviews independently rated by four raters. Sensitivity to change was
evaluated in a subsample of 149 patients. Convergent and discriminant validity
was examined by comparing H-YBOCS-M scores to other measures adminis-
tered. Item clustering was examined with confirmatory and exploratory factor
analyses. Results: The H-YBOCS-M demonstrated good internal consistency,
interrater and test–retest reliability, and sensitivity to symptom change with
treatment. Construct validity was supported by significant higher correlations
with scores on other measures of hypochondriasis than with nonhypochondriacal
measures. Improvement over time in response to treatment correlated with im-
provement both on measures of hypochondriasis and on measures of somatization,
depression, anxiety, and functional status. Confirmatory factor analysis did not
show adequate fit for a three-factor model. Exploratory factor analysis revealed a
five-factor solution with the first two factors consistent with the separation of the
H-YBOCS-M items into the subscales of illness-related avoidance and compul-
sions. Conclusions: H-YBOCS-M appears to be valid, reliable, and appropriate
as an outcome measure for treatment studies of illness anxiety. Study results
highlight “avoidance” as a key feature of illness anxiety—with potentially im-
portant nosologic and treatment implications. Depression and Anxiety 00:1–13,
2012. 
C 2012 Wiley Periodicals, Inc.

Key words: assessment; diagnosis; measurement; psychometrics; illness anxi-

ety; hypochondriasis; anxiety; anxiety disorders; obsessive-compulsive disorder
(OCD); health services

1 Schoolof Social Work & Department of Psychiatry, Columbia

Contract grant sponsor: National Institute of Mental Health research
University, New York
2 Department grants; Contract grant numbers: 5R01MH071688; 5R01MH071456.
of Psychology, Rutgers University, New
∗ Correspondence to: Natalia A. Skritskaya, Ph.D., School of Social
Brunswick, New Jersey
3 Department of Psychiatry, Columbia University, New York Work, Columbia University, 1255 Amsterdam Ave., Room 835, New
4 Department of Psychiatry, Harvard Medical School, Boston, York, NY 10027. E-mail: skritsk@nyspi.columbia.edu
Massachusetts Received for publication 25 November 2011; Revised 28 February
5 Department of Psychiatry, Brigham & Women’s Hospital, 2012; Accepted 10 March 2012
Boston, Massachusetts DOI 10.1002/da.21949
6 Department of Psychiatry, New York State Psychiatric Insti-
Published online in Wiley Online Library (wileyonlinelibrary.com).
tute
C 2012 Wiley Periodicals, Inc.
2 Skritskaya et al.

Hypochondriasis is characterized by preoccupation with replication and extension of the initial psychometric ar-
the fear or belief of having a serious disease, based on a ticle on the H-YBOCS.[14] The extension in this reports
misinterpretation of normal bodily symptoms that per- refers to: (a) a comparison of the sensitivity to change
sists despite medical reassurance.[1] It exerts a heavy toll for the H-YBOCS-M with measures of change on other
on the afflicted individuals and on national health-care dimensions of psychopathology; (b) the determination
resources.[2, 3] It is also a common disorder in the primary of whether a measure of quality of life relates to either
care population in the United States, with an estimated baseline or change scores on the H-YBOCS-M; and (c)
prevalence of 4%.[4] In the last decade, hypochondriasis a psychometric assessment of this revised version that
(also referred to as health anxiety or illness anxiety) has includes new items and a new self-report component (a
received increased research attention, both phenomeno- Symptom Checklist). Both the Checklist and the Ques-
logically and therapeutically.[5–7] However, the lack of tionnaire are included in the Appendix.
consistently used and validated clinician-administered Our prior research[7] used an unpublished
measures limits researchers’ ability to adequately assess hypochondriasis-modified version of the Y-BOCS
severity and treatment effectiveness.[8] (labeled CHIC-OCS—“Columbia Heightened Ill-
Currently, there are two widely used well-validated, ness Concern-Obsessive Compulsive Scale”). The
self-report measures of hypochondriasis severity: the H-YBOCS and H-YBOCS-M represent an improve-
Whiteley Index[9] and the Illness Attitude Scale.[10] ment on the CHIC-OCS by including a major section
These measures, although excellent for assessing illness- on avoidance behaviors. One feature of hypochon-
related cognitions and fears, do not adequately as- driasis that neither the original H-YBOCS nor the
sess other important features of hypochondriasis—such CHIC-OCS was designed to measure however was
as illness-related behaviors (e.g., reassurance seeking) the waxing and waning quality of illness-related
and illness-related avoidance. In the assessment of the anxiety. Unlike the intrusions and compulsions in
severity of other disorders characterized by obsessional OCD that are typically a daily experience, the illness
thoughts, clinician-administered measures have been worries and behaviors of the hypochondriacal patient
developed that examine not only repetitive thoughts can have a wider range of frequency—from daily to
but also the behaviors conducted in response to these less than once a week. Therefore, to enhance the
thoughts. These sensitive and reliable instruments— measurement of illness anxiety severity, our revised
such as the Yale-Brown Obsessive Compulsive Scale instrument (i.e., H-YBOCS-M) has added items that
(Y-BOCS)[11, 12] to assess obsessive-compulsive disorder specifically assess frequency (number of days per week
(OCD) and the BDD-YBOCS[13] to assess body dysmor- in which there are illness-related worries, behaviors, or
phic disorder—quantify the impact of obsessive thoughts avoidance).
and behaviors not by evaluating the symptom’s idiosyn- Five additional modifications distinguish the H-
cratic content but by assessing thoughts and behaviors YBOCS-M from the H-YBOCS. First, retaining the
along the dimensions of duration, functional interfer- convention in the original Y-BOCS, the insight item
ence, distress, and the degree to which the patient can of the H-YBOCS-M is considered an independent item
resist or control the symptoms. Neither the Whiteley and is not included in the calculation of the total sever-
Index nor the Illness Attitudes Scale assesses all of these ity score. Second, to help the interviewer identify the
dimensions. most prominent manifestations of illness anxiety, a self-
More recently, the psychometric properties of report Checklist has been added to the H-BOCS-M
a clinician-administered instrument for assessing that itemizes many common illness-related obsessions,
hypochondriasis (the H-YBOCS) were published.[14] As compulsions, and avoidance behaviors; a similar check-
the first validated, clinician-administered instrument to list approach guides the interviewer in the use of the
assess illness anxiety, this scale represents a significant Y-BOCS for OCD and was used in the CHIC-OCS.
advance in the field. The H-YBOCS was modeled after Third, because patients with health anxiety view the
the Y-BOCS and therefore assesses symptoms by exam- term “hypochondriac” as pejorative, the H-YBOCS-M
ining time, distress, resistance, control, and functional has replaced the term “hypochondriacal” with phrases
interference. Because both OCD and hypochondriasis that ask about fears of “illness” or “a serious disease.”
share similar phenomenology (obsessive thoughts and This terminology is also consistent with the changes
compulsive behaviors), the use of the Y-BOCS as a model proposed for the Somatic Symptom Disorder section of
for the development of a measure of illness anxiety was DSM-5 in which the term hypochondriasis is replaced by
a logical step.[15, 16] Although the H-YBOCS retains the such terms as “illness anxiety” and “health anxiety.”[17]
dimensional format of the original Y-BOCS, it also ex- Fourth, in the assessment of distress associated with
pands upon the Y-BOCS by including item clusters that illness-related behaviors, the H-YBOCS-M phrases the
measure not only obsessive thinking and compulsive be- question quite differently from the H-YBOCS. Because
havior, but also avoidance. reassurance seeking in hypochondriasis is often ego-
This article reports on the psychometric validation of syntonic and experienced at least temporarily as a source
a modified version of the H-YBOCS, termed as the H- of relief, this item in the H-YBOCS-M is phrased to
YBOCS-M. Because of the close similarity between the assess the degree of distress that would arise if check-
two instruments, this report should be considered both a ing and reassurance-seeking behaviors were prevented,

Depression and Anxiety

 Research Article: Development of the Hypochondriasis-YBOCS-Modified 3

whereas in the H-YBOCS, the corollary question asks matosensory Amplification Scale (SSAS).[22] The Whiteley Index is
about distress associated with seeking of reassurance it- a well-validated self-report measure of hypochondriasis severity that
self. Finally, the H-YBOCS-M adds an instructional sec- is the most widely used measure of hypochondriasis in the published
tion to assist in the assessment of avoidance and an item literature. The HIC Severity is a clinician-administered instrument
focusing on the patient’s most intense episode of hypochondriasis in
asking about the number of situations that the patient
the prior 2 weeks. The PHQ-15 is a brief self-administered screen-
currently avoids.
ing measure of somatization that has been shown to have good psy-
chometric properties,[23] whereas the SSAS is a 10-item self-report
that assesses sensitivity to ambiguous, distressing bodily discom-
MATERIALS AND METHODS fort.
SAMPLE To assess discriminant validity, baseline H-YBOCS-M scores for
the 195 participants were compared to scores on the Beck Depres-
The data for this psychometric study, collected 2006–2011, came
sion Inventory-II (BDI-II),[24] State-Trait Anxiety Inventory, Form
from a dual-site, randomized, controlled treatment study of hypochon-
Y, State subscale (STAI),[25] Quality of Life Enjoyment and Satis-
driasis comparing pharmacological, cognitive-behavioral, and com-
faction Questionnaire (Q-LES-Q Short Form [SF]),[26] the Sickness
bined treatments. The study protocol was approved by the institu-
Impact Profile (SIP),[27] as well as age and race of the participants.
tional review boards of the New York State Psychiatric Institute and
BDI-II is a validated self-report measure of depression severity. STAI
the Brigham Women’s Hospital and all patients provided signed in-
is a validated measure of anxiety in adults. Q-LES-Q SF is a validated
formed consent.
measure of perceived quality of life and satisfaction. The SIP is a vali-
All patients met DSM-IV criteria for hypochondriasis, estab-
dated behaviorally based self-report measure of functional impairment
lished with the Structured Diagnostic Interview for Hypochondri-
whose total score covers 12 areas, encompassing physical, psychosocial,
asis (SDIH).[18] Comorbid diagnoses were assessed with the Mini-
vocational, and recreational activities.
International Neuropsychiatric Interview (M.I.N.I.).[19] Patients were
Sensitivity of the H-YBOCS-M to change with treatment was eval-
recruited through print and Internet ads and doctor referrals. Evalu-
uated using the full sample of 149 patients who completed the first
ations before the start of the treatment conducted with 195 consecu-
12 weeks of treatment in the study. Percentage change was calcu-
tively enrolled participants are included in this report. The subsample
lated as follows: [(baseline score − week 12 score)/baseline score] ×
for sensitivity to change includes all 149 patients for whom ratings at
100. To further test the ability of the H-YBOCS-M to detect changes
baseline and week 12 were obtained.
in hypochondriacal symptoms, point biserial correlations for the per-
centage change in scores were calculated between the H-YBOCS-M
STUDY INSTRUMENT and the Whiteley Index, HIC Severity Scale, SSAS, PHQ-15, BDI-II,
First, the patient completes the Illness Concern Checklist, which STAI, Q-LES-Q SF, and SIP.
lists a variety of illness-related worries, behaviors, and avoidance. Next,
the interviewer reviews with the patient which disease-related symp- STATISTICAL ANALYSIS
toms should serve as the primary targets for questions during the H-
To evaluate interrater and test–retest reliability, intraclass corre-
YBOCS-M interview. The H-YBOCS-M is a 19-item semistructured,
lation coefficients (ICCs) were used; Cronbach’s alpha coefficient was
clinician-administered instrument designed to assess the severity of
used to evaluate internal consistency. Pearson’s correlation coefficients
illness worries, behaviors, and avoidance during the previous 2 weeks.
were used to evaluate convergent and discriminant validity. Sensitivity
Similar to the Y-BOCS, the H-YBOCS-M has specific probes for each
to change was evaluated with t-tests, percentage change and Cohen’s
item and the individual item scores range from 0 to 4 with the larger
d effect sizes comparing baseline and week 12 scores. Significance re-
score indicating higher symptom severity. The H-YBOCS-M total
quired an α-level <.05.
severity score is the sum of items 1 through 18.
To assess the construct validity of the three subscales, we employed
The instrument contains three clinically derived subscales: illness
confirmatory factor analysis (CFA; PROC CALIS procedure in SAS).
worries, illness-related behaviors and unhealthy avoidance. Each of
It was applied to the raw score of the 18-item H-YBOCS-M of the
the subscales consists of six items with the sum of the six items pro-
whole sample of 195 participants to verify the hypothesized three-
ducing a composite subscale severity score. Within each subscale, the
factor structure. To determine the adequacy of model fit to the data,
items examine frequency, time spent, interference, distress, resistance,
several fit statistics were estimated: the Chi-square (χ 2 ) goodness-of-
and degree of control. Item 19 indicates degree of insight and is not
fit (GFI) statistics, the absolute fit indices (the GFI, root mean square
included in the composite severity score calculations.
error of approximate [RMSEA]), and the incremental fit indices (the
Bentler’s comparative fit index [CFI], normed fit index [NFI], Bentler
PROCEDURES and Bonett’s nonnormed fit index [NNFI]). Acceptable model fit is
Interrater reliability was assessed by blind audit of a random se- indicated by a χ 2 value close to zero and a χ 2 probability ≥ 0.05, GFI,
lection of 27 audiotaped interviews with 25 participants conducted by CFI, NFI, and NNFI values ≥ 0.90 and an RMSEA value ≤ 0.06.[28]
independent evaluators. Each of these interviews was rated indepen- Subsequent exploratory factor analysis (EFA; PROC FACTOR pro-
dently by three other raters. For two of the audiotaped interviews, the cedure in SAS) with promax rotation was performed to identify the
same participant was used twice, but ratings were conducted on as- number of latent constructs and determine the factor structure. The
sessments collected at two different phases of treatment. Test–retest number of factors was determined by examining the eigenvalues, scree
reliability was assessed in 20 participants by the same rater with an plot, and significant factor loadings.
interval of 1 week either before the start or after completion of the
treatment phase of the study.
To assess convergent validity, baseline H-YBOCS-M scores for RESULTS
the 195 participants were compared to other measures of hypochon-
PATIENT SAMPLE
driasis and/or somatization administered at the same visit—the
Whiteley Index,[9] Heightened Illness Concern-Severity Scale (HIC- The mean age of the 195 participants was 39.7 ± 14.3
Severity),[20] Patient Health Questionnaire-15 (PHQ-15),[21] and So- years and 56.4% were females, 64.1% self-identified as
Depression and Anxiety
4 Skritskaya et al.

White, 16.4% Black, 5.1% Asian, and 14.3% were of RELIABILITY

other racial background. Current Axis I comorbidity was Interrater (Table 1) and test–retest reliability were
common: major depression (33.3%), generalized anxiety excellent. ICCs for test–retest reliability and interrater
disorder (28.1%), panic disorder (14.6%), OCD (13%), agreement were .99 for total H-YBOCS-M scores. For
and somatization disorder (11%). item 19 (insight), ICCs were .87 for test–retest and .82
The subsample of 149 patients who completed 12 for interrater reliability (data were available only on 19
weeks of treatment had a mean age of 41.0 ± 14.6 years interviews). Cronbach’s alpha coefficient for the 18-item
and 59.1% were females; the ethnicity was 64.4% White, version was α = .87, and for the 19-item version α = .85.
16.8% Black, 5.4% Asian, and 13.4% other. For the subscales, Cronbach’s alpha coefficients were .67
The subsample of 25 participants for interrater relia- for illness worries, .82 for illness-related behaviors, and
bility had a mean age of 43.4 ± 15.4 years and 48.0% were .92 for avoidance.
females; the ethnicity was 60.0% White, 28.0% Black, Table 1 also shows Pearson’s product–moment cor-
and 12.0% other. The subsample of 20 participants for relations between each individual item and the 18-item
test–retest reliability had a mean age of 36.6 ± 13.2 years total score minus that item. All except two items (5—
and 60.0% were females; the ethnicity was 55.0% White, resistance against illness worries, and 19–insight) had
15.0% Black, 5.0% Asian, and 25.0% other. significant correlations with the 18-item total score,
ranging from .17 to .70.
ANALYSIS OF INDIVIDUAL ITEMS
Each item was frequently endorsed with scores cover- CONVERGENT AND DISCRIMINANT VALIDITY
ing the range of symptom severity (Table 1). No one was The H-YBOCS-M total scores were significantly pos-
free from illness worries or distress from them (items 1, itively correlated with other measures of hypochon-
2, and 4). Means and standard deviations are presented driasis severity, including the Whiteley Index (r =
in Table 1. .45) and HIC Severity (r = .51; Table 2), support-
ing the convergent validity. Correlations with measures
of somatic amplification (SSAS) and distress from so-
TABLE 1. H-YBOCS-M mean scores and observed matic symptoms (PHQ-15) were lower but significant
range, interrater reliability intraclass correlation for the total severity score (r = .28 and .17, respec-
coefficients and correlations of individual items with the tively). The BDI-II and STAI were selected to assess
total score (N = 195) discriminant validity. The H-YBOCS-M total score
correlations with the BDI-II (r = .19) and the STAI
Range of
(r = .35) were significant, but low to moderate in size
Item M SD scores ICCs r
(Table 2). Partial correlation (r = .049, P = .50) be-
Worries tween the H-YBOCS-M and the BDI-II after removing
1. Time 2.35 0.96 1–4 .96b .44b the contribution of the Whiteley Index was not signifi-
2. Frequency 3.26 0.87 1–4 .92b .21a cant. The BDI-II did not add significant information be-
3. Interference 1.61 0.88 0–4 .93b .58b yond the common shared variance with the H-YBOCS-
4. Distress 2.19 0.65 1–4 .99b .36b M and the Whiteley Index. Partial correlation (r = .17,
5. Resistance 1.83 1.10 0–4 .96b .14
6. Degree of control 2.33 0.89 0–4 .96b .42b
Behaviors
7. Time 1.68 0.92 0–4 .91b .61b TABLE 2. Pearson’s correlation coefficients of the
8. Frequency 2.67 1.19 0–4 .86b .41b H-YBOCS-M 18-item total score at baseline and
9. Interference 1.25 0.97 0–4 .87b .58b percent change score at week 12 with other measures
10. Distress 2.05 1.11 0–4 .91b .44b
11. Resistance 2.34 1.36 0–4 .89b .17a H-YBOCS-M total score H-YBOCS-M percent
Scale at baseline (n = 195) change score (n = 149)
12. Degree of control 2.16 1.19 0–4 .83b .57b
Avoidance Whiteley Index . 448b .561b
13. Extent of avoidance 1.49 1.03 0–4 .77b .63b HIC Severity .505b .719b
14. Frequency 2.19 1.52 0–4 .81b .61b SSAS .278b .378b
15. Interference 1.40 1.14 0–4 .87b .70b PHQ-15 .167a .358b
16. Distress 1.81 1.26 0–4 .88b .66b BDI-II .194b .318b
17. Resistance 1.76 1.41 0–4 .86b .57b STAI .352b .274b
18. Degree of control 1.50 1.21 0–4 .87b .63b Q-LES-Q SF − .348b − .168a
SIP total .281b .495b
Total score 35.91 11.11 .96b
Age .012 n/a
19. Insight (n = 180) 2.27 1.12 0–4 .82b −.10 Race − .029 n/a
a Correlation significant at α < .05. a Correlation significant at α < .05.
b Correlation significant at α ≤ .001. b Correlations are significant at α ≤ .01.

Depression and Anxiety

 Research Article: Development of the Hypochondriasis-YBOCS-Modified 5

P = .015) between the H-YBOCS-M and STAI after TABLE 4. Relative fit of confirmatory factor analysis
removing the contribution of the Whiteley Index was model (N = 195).
significant, although small. H-YBOCS-M total scores
Fit statistics Value
were significantly negatively correlated with perceived
quality of life (Q-LES-Q SF) scores (r = −.35) and pos- χ2 395.43
itively correlated with functional status (SIP) scores (r = df 132
.28), but not with participant’s age or race. P-value <.0001
GFI 0.81
RMSEA 0.1014
SENSITIVITY TO CHANGE CFI 0.8483
After 12 weeks of treatment, the mean percent change NNFI 0.82
in the H-YBOCS-M total score was 37.4 percent (SD = NFI 0.79
42.3). Changes in the total and subscale scores were sig-
Note: The fit indices above include the goodness-of-fit index (GFI),
nificant at α < .001 with medium to large effect sizes
root mean square error of approximate (RMSEA), Bentler’s compara-
(Table 3). Percent change scores on the H-YBOCS- tive fit index (CFI), Bentler and Bonett’s nonnormed fit index (NNFI),
M also correlated moderately or higher with percent and normed fit index (NFI).
change scores on other measures of hypochondriasis, so-
matic amplification, physical symptoms, depression, anx-
iety, and functional status (Table 2). At week 12, the H-
YBOCS-M total score significantly negatively correlated TABLE 5. Confirmatory factor analysis loadings
with Q-LES-Q SF score (r = −.46, P < .001), connect- (N = 195)
ing lower hypochondriasis scores with higher perceived
quality of life. Items Factor 1 Factor 2 Factor 3

1. Worry time 0.69

FACTOR STRUCTURE 2. Frequency 0.29
Confirmatory factor analysis. First, the three- 3. Interference 0.70
4. Distress 0.65
factor model comprised illness worries, illness-related
5. Resistance 0.26
behaviors, and avoidance was tested. Items 1–6 were hy- 6. Degree of control 0.55
pothesized to load on the illness worries factor, items 7. Behavior time 0.77
7–12 to load on the illness behaviors factor, and items 8. Frequency 0.63
13–18 on the avoidance factor. Results indicated that this 9. Interference 0.72
model was not an optimal fit; all goodness-of-fit statis- 10. Distress 0.44
tics failed to meet established guidelines (Table 4). Fac- 11. Resistance 0.79
tor loadings presented in Table 5 indicate the strongest 12. Degree of control 0.79
loadings were for avoidance items. 13. Extent of avoidance 0.84
Exploratory factor analysis. Given the absence of 14. Frequency 0.83
15. Interference 0.84
a good fit for these data using CFA, an EFA was con-
16. Distress 0.88
ducted. The principal axis factoring with a promax rota- 17. Resistance 0.76
tion identified five factors based on eigenvalues greater 18. Degree of control 0.81
than 1, the scree plot and loadings of at least .50
(Table 6). The total variance explained by the five fac- Note: All loadings significant at α < .05.
tors was 71.7%. Factor 1 included all six of the avoid-
ance items, with strong loadings ranging between .82 and
.89. This factor was labeled “Avoidance” and explained
34.0% of the variance. All six of the illness-related com-
pulsive behavior items loaded on Factor 2 (loadings from .69 to .83; cross-loading of .55 for item 9). This factor
was labeled “Compulsive Behaviors” and accounted for
15.2% of the variance. Factors 3, 4, and 5 primarily con-
cerned the illness worry subscale items. Factor 3 (Inter-
TABLE 3. Sensitivity to change (N = 149) ference) explained 9.7% of the variance and consisted
of loadings of items 1, 3, 4, and 9 and cross-loading on
Baseline Week 12 item 7. Factor 4 (Worry Control) explained 7.1% of the
Scales M SD M SD t-valuea Cohen’s d variance and consisted of .86 and .74 loadings of items
Illness worries 13.46 3.32 8.57 4.83 12.57 1.18
5 and 6. Factor 5 (Worry Frequency) explained 5.6% of
Behaviors 12.03 5.03 7.10 5.59 8.96 0.93 the variance and consisted of the loading of item 2 and
Avoidance 10.09 6.67 5.85 6.40 7.61 0.65 cross-loading of item 1. Overall, this EFA confirmed the
Total score 35.57 11.23 21.50 14.30 11.63 1.10 item groupings for avoidance and for compulsive behav-
iors, but split the obsessional items into three additional
a Significant at α < .001. factors with some cross-loading.
Depression and Anxiety
6 Skritskaya et al.

TABLE 6. Exploratory factor analysis loadings (N = 195)

Items Factor 1 Factor 2 Factor 3 Factor 4 Factor 5

1. Worry time 0.32 0.11 0.65 0.31 0.50

2. Frequency 0.11 0.13 0.20 0.01 0.91
3. Interference 0.45 0.35 0.81 −0.02 0.13
4. Distress 0.14 0.15 0.71 0.37 0.18
5. Resistance 0.04 0.05 0.09 0.86 0.00
6. Degree of control 0.19 0.32 0.45 0.74 0.12
7. Behavior time 0.31 0.70 0.58 0.11 0.19
8. Frequency 0.12 0.73 0.30 −0.01 0.37
9. Interference 0.41 0.55 0.68 0.03 −0.05
10. Distress 0.20 0.81 0.31 −0.03 −0.15
11. Resistance −0.03 0.69 −0.20 0.23 0.07
12. Degree of control 0.30 0.83 0.35 0.19 0.08
13. Extent of avoidance 0.87 0.18 0.38 −0.03 0.05
14. Frequency 0.87 0.18 0.31 −0.09 0.22
15. Interference 0.85 0.24 0.54 −0.04 0.13
16. Distress 0.89 0.21 0.40 0.02 0.03
17. Resistance 0.82 0.16 0.25 0.13 0.01
18. Degree of control 0.85 0.21 0.34 0.12 0.02
Variance explained (%) 34.1 15.2 9.7 7.1 5.6

Note: Loadings of 0.50 and larger are bolded to illustrate which factor an item loaded on.

DISCUSSION tial support for the factor structure. The EFA segregated
out the six avoidance items as one factor and the six com-
The H-YBOCS-M is a psychometrically sound and pulsive behavior items as a second factor. In parallel, ini-
valid measure for assessing the severity of illness tial models for the Y-BOCS II were not supported by
anxiety in adults with hypochondriasis. The instrument the CFA, but the EFA generally supported separation
covers the key features of illness thoughts, behaviors, between obsessions and compulsions.[29] In that analysis,
and avoidance by examining each along multiple dimen- the interference from obsessions item did not conform to
sions. The instrument is relatively brief and easy to ad- the theoretical model and loaded on both the obsessions
minister. Similar to the Y-BOCS, the H-YBOCS-M is and compulsions factors. Similarly, in the current study,
specifically designed to measure symptom severity and the interference items for obsessions, compulsions, and
does not depend on the idiosyncratic content of worries avoidance loaded together into a separate factor on the
or behaviors. EFA.
The H-YBOCS-M items were endorsed across the Perhaps the most valuable contribution of Greeven
range of severity and correlated significantly with the et al.[14] in their adaptation of the Y-BOCS for
total scores. The 1-week test–retest reliability and in- hypochondriasis was to expand beyond obsessions and
terrater reliability were high. Construct validity was compulsions by including avoidance. Their validation
supported by much stronger correlations with other study supported the segregation of items into these
measures of hypochondriasis than with measures of so- three clusters by use of factor analysis. Although reas-
matic symptoms, depression, anxiety, or perceived qual- surance seeking behaviors and illness-related unhealthy
ity of life. Sensitivity to change in response to treatment avoidance are not among the DSM-IV-TR criteria of
was demonstrated by correlations with improvement on hypochondriasis, they have been cited as important char-
measures of hypochondriasis, somatization, depression, acteristics of the disorder.[14, 30] Indeed, in the proposed
anxiety, and functional status. revision of DSM-5, the new diagnostic category of “Ill-
As had been reported for the Y-BOCS[11] and the ness Anxiety Disorder” specifically includes criteria en-
BDD-YBOCS,[13] the item that measures resistance to compassing illness-related behaviors and avoidance.[17]
obsessive worries had the lowest correlation with the to- Both illness-related behaviors and avoidance subscales
tal 18-item score. Our finding that the insight item was of the H-YBOCS-M performed well psychometrically
not related to the total H-BOCS-M score was similarly in this study.
reported for the BDD-YBOCS.[13] Given that recent research suggests that hypochon-
Although the hypothesis-driven CFA did not support driasis may be better understood as a severe manifesta-
the clinically derived segregation of the 18 items into tion of an illness anxiety disorder,[31,32] the assessment of
three subscales, the exploratory analysis did provide par- avoidance is essential. For example, patients with illness

Depression and Anxiety

 Research Article: Development of the Hypochondriasis-YBOCS-Modified 7

anxiety may avoid situations that provoke symptoms or ern United States, whereas the H-YBOCS used a Dutch
potentially exacerbate the feared illness,[33] such as phys- sample.
ical exertion that triggers palpitations or shortness of Limitations of this study include the method by which
breath. Paradoxically, patients with illness anxiety may interrater reliability was evaluated as audiotaped inter-
also avoid doctors to the point of neglecting health[34] views likely provide an upper bound estimate;[13] a more
because they fear that the medical evaluation will con- stringent test would be for each rater to conduct his or
firm their worst suspicions. To assist clinicians and re- her own interview with each patient. A second limita-
searchers, the H-BOCS-M Checklist includes many ex- tion deals with discriminant validity; although the cor-
amples of avoidance, thus facilitating a more complete relation with the total H-BOCS-M score was higher
assessment of the patient with illness anxiety. Assessment with the hypochondriacal measures (Whiteley Index),
of illness-related worries, behaviors, and avoidance will both the BDI-II and STAI also correlated significantly.
contribute to a better understanding of the phenomenol- The correlation with the BDI-II was low and disap-
ogy and morbidity of hypochondriasis and enable the peared when the partial correlation was examined af-
identification of more effective strategies to treat the dif- ter the contribution of the Whiteley Index was re-
ferent dimensions. It is noteworthy that increased atten- moved. The correlation with the STAI was moderate
tion has been given to avoidance in the newly published in size, but the partial correlation was small after re-
second edition of the Y-BOCS[29] and, as noted above, moving the Whiteley Index’s contribution. These anal-
avoidance is now included as a criterion in the DSM-5 yses suggest that the H-YBOCS-M has good discrim-
draft of Illness Anxiety Disorder.[17] inant validity. Third, because we did not compare the
From a psychometrics perspective, the H-YBOCS-M H-YBOCS and the H-YBOCS-M directly, we cannot
performed comparably to the H-YBOCS. Cronbach’s determine whether the modifications introduced into
alpha, interrater ICCs and convergent and discriminant the H-YBOCS-M represent an improvement upon the
validity for the H-YBOCS[14] and H-YBOCS-M were H-YBOCS or are simply an alternative version. Finally,
very similar. Both measures had significant correlations generalizability of the study results might be limited
with the Whiteley Index and with depression and anx- to patients who are willing to receive treatment for
iety scales. Both measures appear sensitive to change hypochondriasis.
with comparable effect sizes. This report extends the
prior psychometric study of the H-YBOCS by demon-
strating that the change on the H-YBOCS-M scores be-
tween baseline and week 12 correlated significantly with CONCLUSIONS
improvement not only in hypochondriacal concerns, The H-YBOCS-M appears to be a valid and
but also in somatization, anxiety, depression, and func- reliable measure of the severity of illness-related
tional status. The correlation between improvement in thoughts, behaviors, and avoidance. It shows sensitiv-
illness anxiety and behavioral functioning was moder- ity to change and is likely to be a suitable outcome
ately strong (r = .495), whereas the correlation with measure for illness anxiety in clinical and research
perceived quality of life was weak (r = −.168); the settings.
discrepancy between these two measures may suggest Further research might investigate whether H-
that concrete behavioral change is a more sensitive or YBOCS-M and its subscales are helpful in identifying
an earlier marker of improvement than the individual’s clinically meaningful patient subgroups. Although H-
self-assessment of satisfaction with his/her life. These YBOCS-M is a clinical scale and is not intended for use
findings suggest that the H-YBOCS-M is an excellent with nonclinical populations, it would be informative to
measure to document improvement over time. This administer this scale to a nonclinical sample to develop
psychometric study also confirms that the H-BOCS-M reference for future comparisons.
has excellent interrater reliability. Although the inter-
rater reliability of the original H-YBOCS was estab-
lished using two experts in the area of hypochondria- Acknowledgments. This work was supported by
sis, our study demonstrated high reliability among four
National Institute of Mental Health research grants
raters from different locations and with different lev-
(5R01MH071688 and 5R01MH071456) awarded to AJB
els of experience. Finally, the H-YBOCS-M was vali-
dated on an English-speaking sample of the Northeast- and BAF.

Depression and Anxiety

8 Skritskaya et al.

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 Research Article: Development of the Hypochondriasis-YBOCS-Modified 9

APPENDIX: ILLNESS-RELATED CHECKLIST

Instructions: Please answer yes or no regarding each of the illness-related concerns, behaviors, and avoidance that you might experience.
Please circle Y or yes and N for no and please rate both current and those that were present only in the past. Thank you.

First, what illnesses do you worry about? _____________________________________________

Typical illness-related concerns Current Past only

1. Belief that you have a serious illness Y N Y N
2. Worry that you might have a serious illness you just heard about Y N Y N
3. Worry that when you have a physical symptom it could indicate a serious disease Y N Y N
4. Thought that you better get your symptom checked out or else it might be too late Y N Y N
5. Thought that doctors/family members aren’t taking your symptoms seriously Y N Y N
6. Worry that you might get a serious disease Y N Y N
7. Worry that doctors aren’t telling you the truth about your symptoms Y N Y N
8. Worry that if you visit someone who is sick, you will get sick Y N Y N
9. Other ________________________________ Y N Y N
10. Other ________________________________ Y N Y N
11. Other ________________________________ Y N Y N

Typical illness-related behaviors

(These are actions aimed at reducing anxiety or worry).
1. Reassurance seeking (either overt or subtle) that symptoms are not signs
of a serious illness or one is not ill
With family members Y N Y N
With friends Y N Y N
With Internet sources, chat rooms or health hot lines Y N Y N
With medical books Y N Y N
With medical professionals Y N Y N
2. Checking of one’s body for signs of disease Y N Y N
3. List-making of one’s symptoms to be sure all is communicated to the doctor Y N Y N
4. Calling back the doctor or health professional to make sure he/she understood what you were conveying or Y N Y N
ordered all of the necessary tests
5. Finding another doctor who may repeat or do more tests Y N Y N
6. Obtaining additional medical tests (more than your primary doctor would want you to get) Y N Y N
7. Other ______________________________ Y N Y N
8. Other ______________________________ Y N Y N
9. Other ______________________________ Y N Y N

Typical unhealthy avoidance behaviors

1. Avoiding doctor’s appointments Y N Y N
2. Avoiding going into hospitals or other places where people are sick Y N Y N
3. Avoiding listening to conversations or stories about disease (TV, radio, friends, family) Y N Y N
4. Avoiding reading information about disease (Internet, news media, medical books) Y N Y N
5. Avoiding reading obituaries or going to funerals Y N Y N
6. Avoiding visiting sick or dying friends/relatives Y N Y N
7. Avoiding activities (e.g., exercise) that bring on the physical symptoms that remind you of disease Y N Y N
8. Avoiding touching your own body or examining yourself Y N Y N
9. Avoiding medical tests or exams by health professionals Y N Y N
10. Avoiding positive pro-social activities because one feels that symptoms & illness concerns Y N Y N
should be the primary focus
11. Other _____________________________ Y N Y N
12. Other _____________________________ Y N Y N
13. Other _____________________________ Y N Y N

Depression and Anxiety

10 Skritskaya et al.

H-YBOCS-M
RATING INTERVAL—THE LAST 2 WEEKS
ILLNESS THOUGHTS OR WORRIES (items 1–6)

“I am now going to ask several questions about your concerns that you have or might have a serious illness or disease.” (Make specific reference
to the patient’s target illness worries and thoughts.)

1. Time occupied by worries related to illness or disease

Q: When you have a day with worries that you have or might have a serious disease or worry about a symptom suggestive of serious disease,
how much time do these worries last, if you add up all the illness worries of the day? What’s the average total worry duration if you look at
each of the days afflicted by worry?
0 = None
1 = Mild amount of time: less than 1 hr/day
2 = Moderate amount of time: 1 to 3 hr/day
3 = Severe amount of time: greater than 3 and up to 8 hr/day
4 = Extreme amount of time: greater than 8 hr/day or nearly constant
2. Frequency of worries related to illness or disease
Q: How often have you had thoughts that you have or might have an illness or serious disease or worried about a symptom suggestive to you
of a serious disease (in last 2 weeks)?
0 = None
1 = Seldom: less than 1× week
2 = Sometimes: 1–3× week
3 = Often: 4–6× week
4 = Very often: Daily
3. Interference due to thoughts related to illness or disease
Q: How much do your worries about illness or serious disease interfere with your social or work (or role) functioning? Is there anything that
you don’t do because your mind is so preoccupied with thoughts about illness? [If currently not working determine how much performance
would be affected if patient were employed.]
0 = None
1 = Mild, slight interference with social or occupational activities, but overall performance not impaired
2 = Moderate, definite interference with social or occupational performance, but still manageable
3 = Severe, causes substantial impairment in social or occupational performance
4 = Extreme, incapacitating
4. Distress associated with thoughts related to illness or disease
Q: How much distress do your thoughts about illness or serious disease cause you? [In most cases, distress is equated with anxiety. Only rate
anxiety that seems triggered by illness/disease thoughts, not generalized anxiety or anxiety associated with other conditions.]
0 = None
1 = Mild, not too disturbing
2 = Moderate, disturbing, but still manageable
3 = Severe, very disturbing
4 = Extreme, near constant and disabling distress
5. Resistance against thoughts related to illness or disease
Q: When you have a symptom suggestive of a serious disease or the thought of having an illness, how much of an effort do you make to
resist the thoughts about illness or serious disease–to put them out of your mind–to distract yourself? [Only rate effort made to resist, not
success or failure in putting them out of mind?]
0 = Makes an effort to always resist, or symptoms so minimal doesn’t need to actively resist
1 = Tries to resist most of the time
2 = Makes some effort to resist the thoughts
3 = Yields to almost all thoughts without attempting to distract oneself, but does so with some reluctance
4 = Completely and willingly focuses on the thoughts of possibly having a serious disease
6. Degree of control over thoughts related to illness or disease
Q: When you think you have or might have a serious illness or experience a symptom that makes you worry you might have a serious illness,
how much control do you have over your illness thoughts? How successful are you in stopping or diverting your concerns about illness? Can
you dismiss them?
0 = Complete control
1 = Much control, usually able to stop or divert illness thoughts with some effort and concentration
2 = Moderate control, sometimes able to stop or divert illness thoughts
3 = Little control, rarely successful in stopping or dismissing thoughts about illness, can only divert attention with difficulty
4 = No control, experienced as completely involuntary, rarely able to even momentarily alter worries about illness and symptoms
Total for illness-related thoughts:________

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 Research Article: Development of the Hypochondriasis-YBOCS-Modified 11

ILLNESS-RELATED BEHAVIORS
“The next several questions are about behaviors that you perform in response to your concerns that you have or might have a serious illness or
disease.” (Reminder: Make specific reference to the patient’s target illness behaviors. Make a clear distinction between active purposeful
behaviors and avoidance. Do not include avoidance.)
7. Time occupied by behaviors related to illness concerns
Q: When you have a day when illness concerns arise, on average if you put all of the illness-related behaviors together for that particular
day, how much time would it take? [These must be observable behaviors. For this scale, silent mental reviewing does not count as a
compulsive behavior.]
0 = None
1 = Mild amount of time: less than 1 hr/day
2 = Moderate amount of time: 1 to 3 hr/day
3 = Severe amount of time: greater than 3 and up to 8 hr/day
4 = Extreme amount of time: greater than 8 hr/day or nearly constant
8. Frequency of behaviors related to your illness concerns
Q: How often have you had behaviors related to your concerns that you have or might have a serious illness?
0 = None
1 = Seldom: less than 1× week
2 = Sometimes: 1–3× week
3 = Often: 4–6× week
4 = Very often: Daily
9. Interference due to behaviors in response to illness concerns
Q: How much does your behavior in response to illness concern interfere with your social or work (or role) functioning? [If currently not
working determine how much performance would be affected if patient were employed.]
0 = None
1 = Mild, slight interference with social or occupational activities, but overall performance not impaired
2 = Moderate, definite interference with social or occupational performance, but still manageable
3 = Severe, causes substantial impairment in social or occupational performance
4 = Extreme, incapacitating
10. Distress associated with behaviors in response to illness concerns
Q: How would you feel if you were prevented from performing an illness related behavior? How would you feel if you were prevented from
checking or from seeking reassurance? How anxious would you become?
0 = None
1 = Mild, only slightly anxious if behaviors were prevented
2 = Moderate, anxiety would mount but remain manageable
3 = Severe and very disturbing increase in anxiety if behaviors were prevented or interrupted
4 = Extreme, incapacitating anxiety from any intervention aimed at preventing behaviors or reassurance seeking
11. Resistance against behaviors related to illness concerns
Q: How much of an effort do you make to resist the illness related behaviors? [Only rate effort made to resist, not success or failure in
actually controlling the behaviors]?
0 = Makes an effort to always resist, or symptoms so minimal doesn’t need to actively resist
1 = Tries to resist most of the time
2 = Makes some effort to resist
3 = Yields to almost all behaviors without attempting to control them, but does so with some reluctance
4 = Completely and willingly yields to all behaviors aimed at reducing illness concerns
12. Degree of control over behaviors related to illness concerns
Q: How strong is the drive to perform the illness-related behavior? How much control do you have over your illness-related behaviors?
How successful are you in stopping or diverting your behaviors?
0 = Complete control
1 = Much control, experiences pressure to perform behavior but usually able to exercise voluntary control over it
2 = Moderate control, strong pressure to perform behavior, can control it only with difficulty
3 = Little control, very strong drive to perform the behavior. Must be carried to completion, but sometimes the behavior can be delayed
4 = No control, experienced as completely involuntary, rarely able to even momentarily divert the behavior
Total for illness-related behaviors: ______

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12 Skritskaya et al.

ILLNESS-RELATED UNHEALTHY AVOIDANCE

The remaining questions are about avoidance of situations following from fears or conviction of illness. Please note that this refers to unhealthy
avoidance. In other words, this is avoidance stemming from fear of exposure to situations that a healthy person would not avoid. If avoidance
is a healthy behavior for the patient, then it should not be considered “unhealthy avoidance” and should not be rated here. If a feared
situation is not normally encountered, please ask the patient to rate the following items as if the opportunity for exposure to that situation
was present on a daily basis. (Make specific references to the patient’s avoidance behaviors.)
13. Extent of avoidance related to illness concerns
Q: How many different situations would you currently avoid (if placed in that situation) that are related to your concerns that you might
have a serious illness or disease? [See the checklist for typical avoidance. Situations are overall themes, e.g., avoidance of physical exertion
would be one theme that includes not taking the stairs, avoiding exercise or running after a bus, etc.]
0 = None
1 = Minimal: no more than one situation
2 = Moderate: two or three situations
3 = Severe: many situations
4 = Extreme: every situation that had any reminder of illness, death, or disease
14. Frequency of avoidance related to illness concerns
Q: How many days during the week would you now seek to avoid illness-related situations or reminders? [If the situation is not normally
encountered, ask if avoidance would occur if encountered (hypothetically)?]
0 = None
1 = Seldom: less than 1× week
2 = Sometimes: 1–3× week
3 = Often: 4–6× week
4 = Very often: daily (as often as possible)
15. Interference due to avoidance
Q: How much do your avoidance behaviors related to concerns about serious illness or disease interfere with your social or work (or role)
functioning or with obtaining appropriate medical monitoring? In other words, by avoiding or not doing things, are you limiting your social
or work life or potentially harming your own health? [Rate the avoidance that causes the most interference.]
0 = None
1 = Mild, slight interference with social or occupational activities or medical monitoring, but overall performance or health evaluations
not impaired
2 = Moderate, definite interference with social or occupational performance or medical monitoring, but still manageable and does get
medical check-ups every few years or if absolutely needed
3 = Severe, causes substantial impairment in social or occupational performance or medical monitoring is impaired (because person
avoids getting tests that are recommended or needed)
4 = Extreme, incapacitating interference with social or work functioning or medical care (i.e., would not go for medical care even if one
were quite ill or if there was a strong suspicion one were medically ill . . . or would not go to a hospital if that were part of one’s job)
16. Distress associated with exposure to the avoided situation
Q: How would you feel if you were prevented from avoiding these situations or if you were asked not to avoid? How anxious would you
become? [Rate degree of distress patient would experience if exposed to the avoided situation without being able to get reassurance. Rate the
situation most feared or associated with the greatest distress.]
0 = None
1 = Mild only slightly anxious if exposed to the avoided situation
2 = Moderate, reports that anxiety would mount but remain manageable if exposed to the avoided situation or that anxiety increases but
remains manageable
3 = Severe, prominent and very disturbing increase in anxiety if exposed to the avoided situation
4 = Extreme, incapacitating anxiety if exposed to the avoided situation
17. Resistance against avoidance
Q: How much of an effort do you make to resist the avoidance (i.e., allow exposure of oneself to the illness-related situations)? [Only rate
effort made to resist the avoidance, not success or failure in actually controlling the avoidance.]
0 = Makes an effort to always resist, or symptoms so minimal doesn’t need to actively resist
1 = Tries to resist the avoidance of illness-related situations most of the time
2 = Makes some effort to resist the avoidance of illness-related situations
3 = Yields to almost all avoidance without attempting to control it, but does so with some reluctance (i.e., would avoid exposure to feared
situation but with some reluctance)
4 = Completely and willingly yields to all illness-related avoidance
18. Degree of control over illness-related unhealthy avoidance
Q: How strong is the drive to avoid exposure to the feared situation? How much control do you have over the avoidance?
0 = Complete control
1 = Much control, experiences pressure, but usually able to allow exposure.
2 = Moderate control, strong pressure to avoid exposure, can prevent it only with difficulty
3 = Little control, very strong drive to avoid exposure, can only allow it with extreme difficulty
4 = No control, the need to avoid exposure is completely overpowering
Total for illness-related avoidance: ______
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 Research Article: Development of the Hypochondriasis-YBOCS-Modified 13

19. Insight into illness-related obsessive thoughts

Q: How often do you think your concerns or behaviors are unreasonable? What part of the time do you realize your illness worries are
unreasonable?
0 = Excellent insight, evaluates illness-related obsessive thoughts always as unreasonable
1 = Good insight, evaluates illness-related obsessive thoughts as unreasonable most of the time (≥ 75% of the time)
2 = Fair insight, evaluates illness-related obsessive thoughts as unreasonable much of the time (≥50%, but <75% of the time)
3 = Poor insight, evaluates illness-related obsessive thoughts as unreasonable only some of the time (≥25%, but <50% of the time)
4 = Rare insight, rarely evaluates the illness-related obsessive thoughts as unreasonable (<25% of the time)

Total for illness thoughts/concerns (items1–6): _________

Total for illness-related behaviors (items 7–12): _________
Total for items 1–12: _________
Total for illness-related avoidance (items 13–18): _________
Grand total (items 1–18): _________

Depression and Anxiety