SOCIAL BEHAVIOR AND PERSONALITY, 2014, 42(7), 1183-1190

Society for Personality Research

http://dx.doi.org/10.2224/sbp.2014.42.7.1183

EFFECTS OF DISPOSITIONAL COPING STRATEGY AND

LEVEL OF HEALTH ANXIETY ON ATTENTIONAL BIAS

SUJIN KIM, KIHO KIM, AND JANG-HAN LEE

Chung-Ang University

We examined the influence of dispositional coping strategy and level of health anxiety (HA)
on attentional bias in regard to health-related stimuli. In a dot-probe task participants were
exposed to health and nonhealth-related words for 1,250 ms. The high HA group showed
significantly greater attentional bias in regard to health stimuli compared to the low HA
group. In addition, in the low HA group there was no difference in attentional bias toward
health-related words according to whether they were blunters (cognitively avoidant) or
monitors (vigilant for information), but in the group with high HA blunters showed stronger
attentional bias for health stimuli compared to monitors. Our results in this study confirmed
that not only did individuals with HA show a bias toward selective attention to health-related
information, but also that this bias was affected by their dispositional coping strategy.

Keywords: health anxiety, coping strategy, attentional bias, attention.

Biases in selective attention to internal or external illness information have been

identified as an important individual characteristic that affects the maintenance
or development of health anxiety (Kellner, 1986; Warwick & Salkovskis, 1990).
However, selective attention does not necessarily indicate the maintenance
of attention because the attentional system is not unitary (Mogg, Bradley, De
Bono, & Painter, 1997). Individuals who are anxious about their health may pay
attention to health stimuli that trigger their anxiety because of the automatically
selective attention process. It has not been established whether individuals with
health anxiety (HA) maintain their attention on, or shift their attention from,
such stimuli because little is yet known about the time course of attentional bias
(Jasper & Witthft, 2011).

Sujin Kim, Kiho Kim, and Jang-Han Lee, Department of Psychology, Chung-Ang University.
Correspondence concerning this article should be addressed to: Jang-Han Lee, Department of
Psychology, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 156-756, Republic of
Korea. Email: clipsy@cau.ac.kr

1183
1184 HEALTH ANXIETY AND COPING STRATEGY

In order to increase understanding of attentional systems in relation to

anxiety, Krohne (1993) proposed a model of coping mode (MCM) in which the
process of attention appraisal under stressful and anxiety-producing conditions
is explained. According to this model, there are two ways of coping with
information about a threatening, aversive event: vigilance (VIG) and cognitive
avoidance (CAV). Miller (1987) also suggested that there are two dispositional
strategies for coping with threatening events: monitoring and blunting. Monitors
(individuals with VIG) are predominantly alert for, and sensitive to, threat-
relevant information; in contrast, blunters (individuals with CAV) avoid
threat-related information. Researchers have posited that blunters should orient
away from attention toward the threat, whereas monitors should orient attention
toward the threat. Furthermore, CAV is predicted to play a crucial role in the
development or maintenance of HA (Hadjistavropoulos, Hadjistavropoulos, &
Quine, 2000). Attentional avoidance increases the probability that innocuous
physical sensations will be perceived as unpleasant (Cioffi & Holloway, 1993). A
brief exposure to threat or anxiety-producing stimuli interferes with habituation
to anxiety (Mogg, Mathews, & Weinman, 1987). As a result, the coping strategy
used by individuals with HA could affect their perception and hypervigilance
about health-related information.
Our purpose in this study was to investigate the effect of the coping strategy
used by individuals with either high or low HA on their attentional process in
reacting to health-related stimuli. Considering the nature of coping strategies, we
concluded that a long exposure time to the stimuli would be needed in order to
examine whether individuals with HA maintain their attention on, or shift their
attention from, health-related information according to their coping strategy. We
used a dot-probe task with an exposure duration of 1,250 ms, which we deemed
to be sufficiently long, and likely to be adequately sensitive, in assessing the shift
or maintenance of attention between items in a stimulus pair (Bradley, Mogg,
Falla, & Hamilton, 1998). Based on the assumption that coping strategies reflect
individual differences in information processing, we hypothesized that monitors
with high HA would show strong attentional bias toward health-related stimuli
compared to blunters with high HA, and that there would not be any difference
between the two coping strategies in individuals with low HA. Finally, we
hypothesized that individuals with high HA would show stronger attentional bias
toward health-related stimuli than would those with low HA.

Method

Participants and Measures

We asked 450 undergraduate students to complete the Illness Attitudes Scale
(IAS; Kellner, Abbott, Winslow, & Pathak, 1987) and Millers Monitoring-
 HEALTH ANXIETY AND COPING STRATEGY 1185
Blunting Style Scale (MBSS; Miller, 1987) as a screening measure for HA
and coping strategy, respectively. The IAS consists of 27 items with responses
rated on a 5-point Likert scale ranging from 1 = not at all to 5 = very much
so. Participants who scored in the top 20% for the IAS were selected for the
high HA (HHA) group; participants who scored in the bottom 20% for the IAS
were selected for the low HA (LHA) group. The MBSS consists of 32 items
with responses rated on a 5-point Likert scale ranging from 1 = not at all to 5
= very much so (van Zuuren & Wolfs, 1991). Based on Millers methodology,
participants were classified as monitors (individuals with VIG) or blunters
(individuals with CAV) using a median split on the MBSS. The median split
procedure has been demonstrated to be useful in a number of previous studies
(Miller, 1987). As a result, a total of 67 participants were selected: 17 in the
HHA-blunter group, 16 in the HHA-monitor group, 16 in the LHA-blunter group,
and 18 in the LHA-monitor group.

Procedure
Study participants initially signed a consent form, and were asked to fill out
both the Trait and State forms of the State-Trait Anxiety Inventory (STAI-T and
STAI-S) in which responses are rated on a 4-point Likert scale ranging from
1 = not at all to 4 = very much so (Spielberger, Gorsuch, & Lushene, 1970).
They were then seated in front of a computer screen to perform the dot-probe
task. The task consisted of 90 trials: 10 practice trials and 80 tests. Each trial
of the dot-probe task began with a central fixation point that was presented at
the center of the screen for 500 ms. Following this fixation point, a randomly
selected stimulus pair of words was presented on the screen for 1,250 ms. The
location of each word was counterbalanced. Participants then indicated where the
probe had appeared by pressing the two buttons labeled L (left, Z key) and R
(right, / key) on the keyboard as soon as possible. Bias scores were obtained by
subtracting the mean reaction time (RT) when the health-related words and probe
were in the same position, from the mean RT when the health-related words and
probe were in different positions.
We obtained the stimuli word pairs from previous studies (Brown, Kosslyn,
Delamater, Fama, & Barsky, 1999; Owens, Asmundson, Hadjistavropoulos,
& Owens, 2004) and from a survey of frequency use of words in the Korean
language (Kim, 2005). To select the words, 50 people assessed the relationship
to health and the emotional valence of 151 words on a 5-point scale ranging from
1 = not at all to 5 = very much so for each dimension. In the end, we selected 20
pairs of health-related and neutral words (see Table 1).
At the end of the task, participants were asked to rate the valence of the
health-related words using a 9-point Likert scale where 1 = very positive, 5 =
neutral, 9 = very negative. The entire experiment lasted approximately 15 minutes.
1186 HEALTH ANXIETY AND COPING STRATEGY

Table 1. Word Pairs Used as Experimental Stimuli

Health-related words Nonhealth-related words
Flu Arithmetic
Acute Gloves
Throes Return to schoola
Chronic Curtain
Addiction Lecturer
Cold Statistics
Illness Glass
Fatigue Lecture
Pain Chair
Disorder Window
Rehabilitation In the doorb
Examination Zipper
Checkup Shampoo
Herbal medicinec Dictionary
Hygiene Board
Nursing Note
Drug store Mathematics
Health Metal
Medical testd Furniture
Nutrition Shoes
Note. Words matched on frequency, word length, and syllable length. Words are translated from
Korean. a, b, c, d One word in Korean.

Results

To test the level of anxiety of the groups, we conducted a 2 (HA: HHA, LHA)
2 (coping strategy: blunter, monitor) analysis of variance (ANOVA) for STAI-T
and STAI-S scores, separately. There were main effects of HA in scores for both
STAI-T F(1, 63) = 22.02, p < .01, 2 = .26, and STAI-S, F(1, 63) = 9.68, p <
.01, 2 = .13. These results indicated that the HHA group was more likely than
the other groups to report anxiety. Details of the results for the four groups are
reported in Table 2.

Table 2. Means and Standard Deviations of Self-Report Measures

High health anxiety Low health anxiety
Blunter Monitor Blunter Monitor
(n = 17) (n = 16) (n = 16) (n = 18)

STAI-Ta 23.88 (8.96) 27.94 (9.17) 17.17 (6.60) 16.44 (6.70)

STAI-Sb 20.56 (7.82) 21.41 (12.03) 14.78 (6.31) 14.00 (7.42)
Rating scorec 5.38 (0.44) 5.55 (0.76) 5.03 (0.43) 5.13 (0.92)
Note: aSTAI-T = State-Trait Anxiety Inventory-Trait form; bSTAI-S = State-Trait Anxiety
Inventory-State form; cRating score for health-related words (1 = very positive, 5 = neutral, 9 = very
negative).
 HEALTH ANXIETY AND COPING STRATEGY 1187
To test the hypothesis that attentional bias in individuals would be different
according to their level of HA and their coping strategy, we conducted a 2 (HA:
HHA, LHA) 2 (coping: blunter, monitor) ANOVA. The results showed a
significant interaction effect between level of HA and coping strategy, F(1, 63)
= 4.38, p < .05, 2 = .07, and a significant main effect of level of HA, F(1, 63) =
6.11, p < .05, 2 = .09. These interaction effects were analyzed through a test of
simple main effects. The results indicated that there was a significant difference
for the HHA group, according to coping strategy, F(1, 63) = 5.59, p < .05;
however, there was no significant difference in attention bias in the LHA group,
F(1, 63) = 0.34, ns. These results indicated that the attention of the HHA group
who used a blunting coping strategy was more oriented toward health words
than was the attention of the HHA group who used a monitoring coping strategy.
Further, among people in the LHA group there was no difference regardless
of the coping strategy they used, in their attentional bias toward health-related
words (see Figure 1).

30
blunter
25
monitor
30
15
Bias score (ms)

10

5
0

-5

-10

-15
High Low
Health anxiety

Figure 1. Differences in attentional bias according to level of health anxiety (HHA vs. LHA)
and coping strategy (blunter vs. monitor).

The rating scores of health-related words were entered into a 2 (HA: HHA,
LHA) 2 (coping: blunter, monitor) ANOVA. The results showed a significant
main effect of HA, F(1, 63) = 4.36, p < .05, 2 = .07. There was no significant
interaction between HA and coping strategy. These results indicated that the
HHA group rated negative health-related words as more negative than did the
LHA group.
1188 HEALTH ANXIETY AND COPING STRATEGY

Discussion

There are two main findings in this study: (a) individuals with HHA showed
stronger attentional bias for health-related stimuli than did those with LHA; (b)
individuals with HHA who used a blunting coping strategy showed stronger
attentional bias for health-related stimuli than did HHA who used a monitoring
strategy. There was no difference in attentional bias for health-related stimuli
between the two coping strategies among individuals with LHA.
These results indicated that a higher level of HA was associated with a greater
attentional bias for health-related stimuli. In the cognitive behavioral model it is
suggested that cognitive variables (e.g., cognitive processing of information) are
involved in the development and maintenance of HA (Salkovskis & Warwick,
2001). Individuals with HA pay attention to physical sensations and stimuli
selectively; thus, they may misinterpret the inner stimuli and sensations as
indicators of illness. In this model, it is posited that not only internal stimuli,
but also external stimuli (e.g., images, information about illness), act to trigger
events in a vicious circle of body sensations, their catastrophic interpretation,
and affective, attentional, behavioral, and physiological consequences that foster
the detection of more body sensations (Warwick, 1989). Our results provide
empirical support for this model: in our study individuals with HHA showed
greater attentional bias for information about health than did those with LHA.
In addition, we found that not only was level of HA related to attentional
bias for health-related stimuli, but also that this attentional bias was affected by
dispositional coping strategy. Specifically, blunters with HHA showed stronger
attentional bias toward health-related stimuli than did monitors with HHA, but
there was no difference in attentional bias between the two coping strategies
in individuals with LHA. Contrary to our prediction, the stimuli exposure
duration time (1,250 ms) used in our study might be insufficient to examine
the late attentional process that reflects shift of an individuals attention from
health-related words. In light of this view, the results we have reported for
monitors with HHA may be explained by Eysencks (1992) hypervigilance
hypothesis of anxiety. At the initial stage of attentional processing, in detecting
potential threat, monitors with HHA would scan the other location, whereas
blunters with HHA might be autonomically susceptible and sensitive to
health-related information.
A notable limitation in our study is that the findings cannot provide information
regarding the late attentional process, but only provide information on the initial
attention pattern of HA based on coping strategy. Although previous researchers
have found significant associations between anxiety sensitivity and attentional
bias toward illness stimuli (Keogh, Dillon, Georgiou, & Hunt, 2001; Lees,
Mogg, & Bradley, 2005), it is, as yet, unclear whether individuals maintain their
 HEALTH ANXIETY AND COPING STRATEGY 1189
attention on, or shift their attention from, such stimuli (Jasper & Witthft, 2011).
To address the difference between early and later attention processes of HA,
distinctions between the early, largely autonomic, process in the detection of the
threat, and the later, controlled thinking processes in reaction to the threat may
need to be tested in future studies using more diverse exposure time(s).
Despite the limitations we have noted, in the present study we have revealed
that different cognitive mechanisms in HA may differ according to the coping
strategy used by the individual. Thus, our findings in this study may provide
empirical support for the idea that the coping strategy, in addition to the
attentional process, plays a specific role in the cognitive mechanisms of an
individuals HA. In addition, this idea implies that, because the attention process
differs based on individual coping strategy, it may be more beneficial to provide
a differentiated approach for each individuals coping strategy.
Overall, in this study we presented the investigation of the relationship
between HA and coping strategy in terms of attentional bias. Individuals showed
a different attentional bias toward health-related stimuli according to the level
of their HA and whether they used a blunting or a monitoring coping strategy.
Therefore, our findings add to the extant literature through suggesting the
significance of the effect of coping strategy in the field of HA.

References

Bradley, B. P., Mogg, K., Falla, S. J., & Hamilton, L. R. (1998). Attentional bias for threatening facial
expressions in anxiety: Manipulation of stimulus duration. Cognition and Emotion, 12, 737-753.
http://doi.org/b4v8f2
Brown, H. D., Kosslyn, S. M., Delamater, B., Fama, J., & Barsky, A. J. (1999). Perceptual and
memory biases for health-related information in hypochondriacal individuals. Journal of
Psychosomatic Research, 47, 67-78.
Cioffi, D., & Holloway, J. (1993). Delayed costs of suppressed pain. Journal of Personality and
Social Psychology, 64, 274-282. http://doi.org/c6xnnp
Eysenck, M. W. (1992). Anxiety: The cognitive perspective. Hove, UK: Erlbaum.
Hadjistavropoulos, H. D., Hadjistavropoulos, T., & Quine, A. (2000). Health anxiety moderates the
effects of distraction versus attention to pain. Behaviour Research and Therapy, 38, 425-438.
http://doi.org/crf2dp
Jasper, F., & Witthft, M. (2011). Health anxiety and attentional bias: The time course of vigilance
and avoidance in light of pictorial illness information. Journal of Anxiety Disorders, 25, 1131-38.
http://doi.org/ffx92j
Keogh, E., Dillon, C., Georgiou, G., & Hunt, C. (2001). Selective attentional biases for physical threat
in physical anxiety sensitivity. Journal of Anxiety Disorders, 15, 299-315. http://doi.org/c4gvzb
Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger Press.
Kellner, R., Abbott, P., Winslow, W. W., & Pathak, D. (1987). Fears, beliefs, and attitudes in DSM-III
hypochondriasis. The Journal of Nervous and Mental Disease, 175, 20-25.
Kim, H. S. (2005). Survey of frequency of use in Korean 2. Seoul, Republic of Korea: The National
Institute of the Korean Language.
1190 HEALTH ANXIETY AND COPING STRATEGY

Krohne, H. W. (1993). Vigilance and cognitive avoidance as concepts in coping research. In H.

W. Krohne (Ed.), Attention and avoidance: Strategies in coping with aversiveness (pp. 19-50).
Seattle, WA: Hogrefe & Huber.
Lees, A., Mogg, K., & Bradley, B. P. (2005). Health anxiety, anxiety sensitivity, and attentional
biases for pictorial and linguistic health-threat cues. Cognition and Emotion, 19, 453-462. http://
doi.org/dcg8xw
Miller, S. M. (1987). Monitoring and blunting: Validation of a questionnaire to assess styles of
information seeking under threat. Journal of Personality and Social Psychology, 52, 345-353.
http://doi.org/d6mrqw
Mogg, K., Bradley, B. P., De Bono, J., & Painter, M. (1997). Time course of attentional bias for threat
information in non-clinical anxiety. Behaviour Research and Therapy, 35, 297-303. http://doi.
org/cng4vg
Mogg, K., Mathews, A., & Weinman, J. (1987). Memory bias in clinical anxiety. Journal of Abnormal
Psychology, 96, 94-98. http://doi.org/d8r5wb
Owens, K. M. B., Asmundson, G. J. G., Hadjistavropoulos, T., & Owens, T. J. (2004). Attentional bias
toward illness threat in individuals with elevated health anxiety. Cognitive Therapy and Research,
28, 57-66. http://doi.org/dqn7c9
Salkovskis, P. M., & Warwick, H. M. C. (2001). Meaning, misinterpretations, and medicine: A cog-
nitive-behavioral approach to understanding health anxiety and hypochondriasis. In V. Starcevic
& D. Lipsitt (Eds.), Hypochondriasis: Modern perspectives on an ancient malady (pp. 202-222).
New York: Guilford Press.
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the State-Trait Anxiety
Inventory. Palo Alto, CA: Consulting Psychologists Press.
van Zuuren, F. J., & Wolfs, H. M. (1991). Styles of information seeking under threat: Personal
and situational aspects of monitoring and blunting. Personality and Individual Differences, 12,
141-149. http://doi.org/bj9b99
Warwick, H. M. C. (1989). A cognitive-behavioural approach to hypochondriasis and health anxiety.
Journal of Psychosomatic Research, 33, 705-711. http://doi.org/c9qbt2
Warwick, H. M. C., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and Therapy,
28, 105-117. http://doi.org/c9skf2
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