The efficacy of exposure-based cognitive behavioral therapy (eCBT) for panic disorder and agoraphobia (PD/AG) is well established, but the mechanisms of action are still under debate. Here we investigated whether increased fear activation (by provoking additional bodily symptoms using interoceptive challenges) during exposure to agoraphobic situations would improve therapy outcome. Individuals diagnosed with PD/AG (N=124) were randomized to one of the two variants of eCBT, with (exposure plus fear activation; E+FA) and without (exposure alone; E) guided evocation of unpleasant body symptoms (using additional interoceptive exposure exercises) and/or threat cognitions (expectations of potential threats that might occur during exposure). Primary outcome measures were assessed at baseline, post treatment, and at four-month follow-up. Reported fear and perceived likelihood of expected threat were assessed as moderators prior to, during, and after exposure sessions using ecological momentary assessment. Post treatment, E+FA was inferior to E in two of four primary outcome measures. At the follow-up assessment, both treatment variants were equally effective in all outcomes. In conclusion, increasing fear activation by explicitly activating the response units of the fear network did not result in better treatment outcome, questioning popular recommendations to maximize patient fear during eCBT - at least for patients with PD/AG.

Stress-induced physiological changes offer insights into autonomic nervous system (ANS) function beyond resting cardiac activity, relevant to both physical and mental illnesses. Limited research exists on heart rate (HR) reactivity in children and adolescents, particularly in the context of internalizing psychopathology. In a study of n = 48 typically developing adolescents (mean age 16.31 years, SD = 0.51), HR and vagal-mediated heart rate variability (vmHRV) were assessed by electrocardiography during an orthostatic challenge, which served as a standardized physiological stressor. Regression models examined the association between HR metrics (baseline, reactivity, recovery) and self-reported internalizing psychopathology (depression and anxiety). Higher levels of internalizing psychopathology were negatively associated with vmHRV reactivity and recovery, and these associations were moderated by sex. Levels of anxiety and depression showed a stronger negative association with vmHRV reactivity in boys than girls, and anxiety levels showed a unique association with reduced vmHRV recovery in boys. These findings highlight sex-specific patterns in ANS functioning related to internalizing symptoms and stress-induced physiological responses in youth.

Körperbezogene repetitive Verhaltensweisen (engl. Abkürzung: BFRBs) werden im deutschsprachigen Raum bislang nicht durch strukturierte klinische Interviews abgebildet. Ziel ist die Entwicklung, Pilotierung und Überarbeitung eines BFRBs-Zusatzmoduls für das Diagnostische Interview bei Psychischen Störungen-Open Access (DIPS-OA). Auf Basis der DSM-5-Kriterien wurde ein strukturiertes BFRBs-Zusatzmodul für das DIPS-OA entwickelt, mit den Untermodulen Trichotillomanie, Dermatillomanie und weitere BFRBs. Es erfolgte eine mehrstufige qualitative und quantitative Evaluation durch Expert:innen und Psychotherapierende (N = 14) mit anschließender Überarbeitung des Moduls. Der Bereich zu Dermatillomanie wurde (N = 78) pilotiert und psychometrisch evaluiert. Die qualitative Evaluation des gesamten Zusatzmoduls durch Expert:innen identifizierte gezielte Optimierungsbedarfe. In der zweiten Evaluation wurde die überarbeitete Version insgesamt gut bis sehr gut bewertet (Mdn = 1,5). Die Pilotierung des Bereichs Dermatillomanie zeigte eine sehr hohe Interrater-Reliabilität (κ = 0,87). Ein Fallbeispiel verdeutlicht die klinische Anwendbarkeit und inhaltliche Passung des Moduls. Die Ergebnisse der Pilotbefunde sind nur als vorläufige Hinweise zu interpretieren, da die umfassende Evaluation des gesamten Zusatzmoduls aktuell noch durchgeführt wird. Mit dem DIPS-OA-Zusatzmodul für BFRBs steht erstmals ein deutschsprachiges strukturiertes Interview zur Diagnostik körperbezogener repetitiver Verhaltensweisen zur Verfügung, welches nach umfassender psychometrischer Evaluation die Versorgungslage von Personen mit BFRBs verbessern kann.

Fear of cancer recurrence (FCR) is one of the most common psychological challenges experienced by breast cancer survivors. This longitudinal qualitative study examines the lived experience of FCR, its evolution over time, and the coping strategies employed by women in remission following a first-time breast cancer diagnosis. Semi-structured telephone interviews were conducted with 28 participants at three time points (T1: within 24 months post-treatment, T2: +3 months, T3: +6 months). Data were analyzed using qualitative content analysis, complemented by quantitative tests (Cochran’s Q, Dunn’s Test) to assess temporal changes. Findings reveal a broad spectrum of situational triggers for FCR, including follow-up medical appointments, physical symptoms, exposure to cancer-related content, and existential concerns. While some participants reported stable or diminishing fear, others described fluctuating or increasing FCR, illustrating the diversity of individual trajectories. Across the interviews, 55 distinct coping strategies emerged, grouped into ten overarching categories - such as active distraction, emotional acceptance, rational thinking, and social support. Although the average number of strategies declined over time, certain approaches—particularly physical activity, direct confrontation of fears, and engagement with mortality—were consistently perceived as particularly helpful. This study highlights the complex and dynamic nature of FCR, highlighting its highly individualized expression and development. The results underscore the importance of personalized psycho-oncological interventions that take into account the personal history and situational context of survivors. By providing a nuanced understanding of the emotional processes and regulation efforts involved in managing FCR, the study contributes valuable insights into how breast cancer survivors adjust to life after treatment and cope with the enduring psychological legacy of cancer.

: Background: Social anxiety models posit increased self-focused attention; however, it remains unclear how attention is allocated to negative (socially relevant symptoms such as blushing) compared with positive (feeling relaxed) self-relevant stimuli. Aims: We examined whether individuals with speech anxiety exhibit a relative attentional bias toward negative versus positive self-relevant stimuli. Method: A total of 66 participants with high or low speech anxiety responded to stimuli during speech anticipation and performance. External stimuli were LEDs on audience members' foreheads; self-relevant stimuli were tones, purportedly indicating arousal or relaxation. Results: Participants responded slower to self-relevant than to external stimuli. No differential bias for negative self-relevant stimuli (arousal) was observed. However, speech-anxious individuals reacted faster to all stimuli during the speech. Conclusion: No evidence was found for a valence-specific attentional bias toward self-relevant stimuli in speech-anxious individuals. Instead, increased overall reactivity during speech performance suggests heightened vigilance or arousal. This points to a generalized attentional sensitivity in socially anxious individuals, rather than selective attention to negative self-relevant cues. Zusammenfassung: Hintergrund: Modelle der sozialen Angst postulieren eine erh & ouml;hte selbstfokussierte Aufmerksamkeit. Unklar ist, wie Aufmerksamkeit f & uuml;r negative (sozial-relevante Symptome wie Err & ouml;ten) im Vergleich zu positiven (z. B. entspannt sein) selbstrelevanter Reizen gesteuert wird. Zielsetzung: Hier wird gepr & uuml;ft, ob sprech & auml;ngstliche Personen eine relative Aufmerksamkeitsverzerrung zugunsten negativer vs. positiver selbstrelevanter Reize zeigen. Methode: 66 Proband_innen mit hoher oder niedriger Redeangst reagierten w & auml;hrend Redeantizipation und -durchf & uuml;hrung auf verschiedene Reize. Externe Reize waren LEDs auf den Stirnen von Zuh & ouml;rer_innen; selbstrelevante Reize waren T & ouml;ne, die angeblich Erregung oder Entspannung anzeigten. Ergebnisse: Reaktionen auf selbstrelevante Reize waren langsamer als auf externe. Ein spezifisches Bias f & uuml;r negative selbstrelevante Reize (Erregung) zeigte sich nicht. Hoch & auml;ngstliche Personen reagierten jedoch w & auml;hrend der Rede schneller auf alle Reize. Schlussfolgerung: Es fand sich kein valenzspezifisches Bias, sondern eine erh & ouml;hte generelle Reaktivit & auml;t, was auf gesteigerte Wachsamkeit bei sozial & auml;ngstlichen Personen hindeutet.

Individuals with Trichotillomania (TTM) or related hair-focused repetitive behaviors engage in recurrent hair pulling that negatively impacts their quality of life. At the same time, hair care remains a central part of their hygiene and beauty routines. This study examined the effects of a mindfulness-based haircut appointment, delivered by trained hair professionals, on pathological hair-pulling behavior. In an open-label intervention study, 43 adult females with TTM completed measures of hair-pulling behavior and maintained hair-pulling diaries for 14 days before and after the appointment. Results showed significant reductions in hair-pulling urges and time spent pulling hair post-appointment, with sustained improvements at 14, 30, and 60 days, as documented in diaries and the Massachusetts General Hospital Hairpulling Scale.Furthermore, participants were satisfied with the appointment, attributing this to the empathy and non-judgmental communication exhibited by the hair professionals. These findings suggest that haircut appointments administered with compassion and understanding may significantly reduce hair-pulling behaviors and improve overall well-being. The results underscore the importance of training hair professionals to provide informed, supportive services to individuals affected by TTM.

Zusammenfassung: Theoretischer Hintergrund: Psychotherapie soll Sicherheit und faire Versorgung bieten, wird für minorisierte Patient_innen jedoch nicht selten zum Schauplatz subtiler Diskriminierungserfahrungen. Von Therapeut_innen getätigte Mikroaggressionen gefährden die therapeutische Allianz und den Behandlungserfolg, insbesondere wenn sie unerkannt bleiben. Fragestellung: In welcher Form treten typische Mikroaggressionen in deutschen Psychotherapien auf? Methode: Schilderungen von N = 278 minorisierten Patient_innen über ihre Erfahrungen mit Rassismus, Sexismus, Hetero- und Cis-Sexismus innerhalb von Psychotherapien wurden in online-Erhebungen gesammelt und inhaltsanalytisch ausgewertet. Ergebnis: Es konnten zehn gängige Typen psychotherapeutischer Mikroaggressionen identifiziert werden. Sie traten über verschiedene Patient_innengruppen sowie unabhängig vom Therapieverfahren auf und spiegeln ein strukturell verankertes Muster subtiler Diskriminierung wider. Schlussfolgerungen: Die vorliegende Taxonomie bietet eine Grundlage, um Sensibilität, Selbstreflexion und kulturelle Demut im psychotherapeutischen Handeln zu stärken.

Objectives: Intolerance of uncertainty (IU) describes a dispositional aversion to uncertainty. Recent research has identified IU as a causal contributor to pervasive decision difficulties (indecisiveness). Given that IU and indecisiveness occur across mental disorders, understanding whether IU's causal role in indecisiveness extends to clinical populations is critical. This study therefore tested the effect of IU on indecisiveness in a clinical sample.Methods: In this pre-registered experiment, N = 154 individuals with formally diagnosed obsessive-compulsive and/or anxiety disorders were randomly assigned to a condition aimed at either increasing or decreasing IU. Subsequently, participants reported their current levels of (situational) IU and, critically, their indecisiveness regarding two personally relevant decisions.Results: The experimental manipulation successfully altered IU levels. Participants with heightened IU exhibited more indecisiveness compared to those with reduced IU, but this effect occurred only indirectly through situational IU. The observed effect sizes were small.Limitations: Compared to preceding research, effect sizes were small and the effect of IU on indecisiveness only manifested itself indirectly. More robust interventions may be necessary to induce more pronounced changes in IU within clinical populations. The reliance on a heterogeneous sample with various diagnoses limits the disorder-specificity of the findings.Conclusions: These results extend the causal role of IU in indecisiveness to mental disorders. The findings suggest IU as a potential approach for addressing problematic indecisiveness.

Background Body-focused repetitive behaviors (BFRBs) are currently not assessed by structured clinical interviews in German-speaking countries. The aim of this study was the development, pilot testing, and iterative revision of a BFRBs add-on module for the diagnostic interview for mental disorders (DIPS-OA). Method Based on the DSM-5 diagnostic criteria, a structured BFRBs supplementary module for the DIPS-OA was developed, with submodules for trichotillomania, dermatillomania and other BFRBs. A multistage qualitative and quantitative evaluation was carried out by experts and psychotherapists (N = 14) followed by a subsequent revision of the module. The dermatillomania section was piloted (N = 78) and psychometrically evaluated. Results The qualitative expert evaluation of the full supplementary module identified specific areas for optimization. In the second evaluation the revised version received overall good to very good ratings (mdn = 1.5). Pilot testing of the dermatillomania section demonstrated very high interrater reliability (kappa = 0.87). A case example illustrates the clinical applicability and conceptual fit of the module. Conclusion The results of the pilot study should be interpreted as preliminary indications as the comprehensive evaluation of the entire supplementary module is currently still ongoing. The DIPS-OA BFRBs add-on module represents the first structured clinical interview for the assessment of BFRBs in German-speaking countries and, following comprehensive psychometric evaluation, has the potential to improve diagnostic assessment and clinical care for individuals with BFRBs.

Understanding the mechanisms underlying pathological safety behavior is crucial for the development of effective treatments for mental disorders. This study investigates the interplay between intolerance of uncertainty (IU), not just right experiences (NJRE), and safety behaviors using a behavior-based checking paradigm in individuals (N = 164) diagnosed with obsessive-compulsive disorder (OCD) and/or anxiety disorders. Findings revealed that IU was related to more disturbance caused by experimentally induced NJRE. In addition, IU was linked to more NJRE on a trait level. Regarding safety behavior in the form of checking, IU was also indirectly associated with longer checking durations via NJRE-related disturbance. This indirect effect supports a conceptual pathway where IU causes NJRE-related disturbance, leading to excessive uncertainty reducing safety behaviors. These results reinforce IU’s role as a transdiagnostic factor driving safety behaviors, which can contribute to maintaining pathology. Furthermore, the findings confirm a mediating role of NJRE in this relationship. Thus, the relevance of NJRE may extend beyond OCD into other anxiety disorders whenever IU is a critical feature. Implications include considering IU and NJRE in therapies across anxiety-related diagnoses as a mitigating factor of pathological safety behaviors. Despite strengths like a large, formally diagnosed sample and a behavior-based paradigm, sample heterogeneity and the use of novel methodology constitute limitations of the study.

Background: Psychotherapy should provide safety and equitable care, but for marginalized patients, it not infrequently becomes a setting for subtle experiences of discrimination. Microaggressions perpetrated by therapists can jeopardize both the therapeutic alliance and the treatment outcome, especially when they go unrecognized. Objective: In what forms do typical microaggressions occur in German psychotherapy? Methods: We collected reports of N = 278 marginalized patients about their experiences with racism, sexism, heterosexism, and cis-sexism during psychotherapy in online surveys and evaluated them using content analysis. Results: We identified ten common types of psychotherapeutic microaggressions that occurred across diverse groups of individual patients and therapeutic approaches and reflect a structurally embedded pattern of subtle discrimination. Conclusions: The presented taxonomy provides a basis for improving awareness, self-reflection, and cultural humility in psychotherapeutic practice.

OBJECTIVES:Intolerance of uncertainty (IU) is characterized by a pervasive negative reaction to uncertainty. It is a transdiagnostic risk factor for various mental disorders. Since decisions often need to be made in the face of uncertainty, IU is associated with indecisiveness, a dispositional difficulty in making decisions. Indecisiveness is also linked to a range of mental disorders. While IU is seen as a causal factor in indecisiveness, experimental studies on this assumption are lacking. METHODS:In this pre-registered, adequately powered study (N = 301), IU was experimentally increased or decreased compared to a control group, and the effect on indecisiveness was observed. Indecisiveness was assessed in a situational context, focusing on two decisions that were personally relevant to participants. RESULTS:The manipulation successfully affected IU. As predicted, increased IU led to more indecisiveness across both decisions compared to decreased IU. Exploratory analyses found that situational IU mediated the effect of the experimental manipulation on indecisiveness. CONCLUSIONS:The results are the first to demonstrate a causal effect of IU on indecisiveness, thus contributing to the explanation of indecisiveness and the role that uncertainty management plays in it. Moreover, they have implications for treating various mental disorders by highlighting the role of IU in the transdiagnostic phenomenon of indecisiveness.

Expectancy violation has been proposed as a potential core mechanism of action in psychotherapy, particularly in exposure therapy for anxiety disorders. However, various relevant expectations have been discussed, and empirical studies examining their significance are still scarce. This study aimed to investigate one specific form of expectancy violation, based on Rachman's (1994) match-mismatch model, specifically by comparing expected and experienced fear and examining their relationship to safety behaviour during exposure in vivo in 268 patients meeting DSM-IV criteria for panic disorder with agoraphobia. Participants underwent exposure to a highly controlled manual-based cognitive behaviour therapy in a randomised multicenter psychotherapy study. Participants tended to overpredict fear during exposure. Both expected and experienced fear significantly decreased over the course of repeated exposure exercises, while prediction (in)accuracy (difference between expected and experienced fear) remained stable. The decrease in expected fear over time was a strong predictor of treatment outcomes for the Bodily Sensations Questionnaire (BSQ) and Panic and Agoraphobia Scale (PAS) at post. Even more, the reduction in expected fear was a significant predictor of treatment success across all outcome measures in the follow-up assessment. These findings suggest that violating excessive fear expectancies is not a necessary condition for symptom reduction during exposure therapy.

Background The experience of regretting parenthood is still associated with stigma. Limited knowledge currently exists about the prevalence and the underlying factors influencing this phenomenon. Objective This study examines the relationships between regret over parenthood and factors such as depression, value of children, demographic variables, and socio-economic background. Methods A hierarchical regression analysis was conducted using data from the 12th wave of the Relationship and Family Panel (pairfam). The sample consisted of 2100 individuals (M = 40.29 years; 62% female, 38% male). Results Eleven percent of the participants reported that they would not or would rather not choose to have children again. Regretting parenthood was associated with a younger parental age, an older age of the youngest child, more pronounced depressive symptoms, higher perceived psychosocial costs of the children, and lower socio-economic status; however, it was not associated with relationship status, gender, or perceived benefits of parenthood. Conclusion Targeted information campaigns should educate young people about the optimal conditions for starting a family and aspects of life planning to prevent regret over parenthood.

Abstract: The conscious engagement with neutral and symptom-related bodily signals (i.e., interoceptive sensibility) is an important transdiagnostic factor whose assessment remains challenging. In two studies, we examined the psychometric properties and the validity of the German Interoceptive Sensitivity and Attention Questionnaire (ISAQ) assessing two convenience samples ( N = 365 and N = 254), adults at risk for rosacea ( N = 376) and 44 outpatients with pathological illness anxiety compared to 40 controls. Confirmatory factor analyses indicated the structure of the German ISAQ is best represented by the 3‐factor model of the original version (F1: sensitivity to neutral bodily sensations, F2: attention to unpleasant bodily sensations, and F3: difficulty disengaging from unpleasant bodily sensations) with an acceptable model fit after consideration of modification indices. Reliability was acceptable for F1 and F2, but poor for F3. Higher correlations of F1 with measures of functional and of F2/F3 with measures of dysfunctional body focus indicated validity. Measurement invariance to the Dutch original was partially met. Persons with illness anxiety scored significantly higher in all ISAQ subscales. Comparable to the original, the German ISAQ is a valid instrument to assess neutral and negative body perception. The third subscale should be interpreted cautiously.

Objective:According to the principles of predictive processing theory, persistent symptom perception is largely determined by central nervous predictions on somatosensory input. Here, we examine how threat-related expectations shape predictions and interoceptive perceptions across body domains using sham EMF (electromagnetic field) exposure. Methods:Participants (n = 113) were recruited via announcements at the university. Most participants were female (76.1 %) with a mean age of 25.12 years. Participants were divided into two groups (sham EMF on/off). Both groups completed a somatic and a cardiovascular signal detection task (SSDT, cvSDT) in pseudo-randomized order. Sensitivities and response biases were calculated. Self-reports (symptom distress, anxiety) were completed. Group effects were analysed with (M)AN(C)OVAs. In four exploratory regression models response bias and anxiety (state/trait) served as predictors for somatic symptom distress. Results:Participants in the sham EMF group reported significantly higher levels of state anxiety (p = .021, d = 0.44) and, trend-wise, more symptoms during the experiment (p = .065, d = 0.35). Response biases did not differ significantly between the groups (SSDT: p = .782; cvSDT: p = .743). However, higher somatic symptom distress was significantly associated with a more liberal interoceptive response tendency in both tasks in the sham EMF group (two significant models, one trend: (-0.209 ≤ βs ≤ -0.325, adjusted 0.232 ≤ R² ≤ 0.330). Conclusions:A liberal approach was associated with elevated symptom experience across bodily domains and might be considered a transdiagnostic psychopathological risk factor. As research is still scarce, replication studies with valid context manipulations are essential.

BACKGROUND:Exposure-based CBT is highly effective in treating patients with panic disorder and agoraphobia; however, access to such treatments is often limited. Smartphone-based self-management apps offer a promising low-threshold treatment alternative to face-to-face therapy. Although such health apps have shown to be effective in reducing anxiety symptoms, comparisons to active treatments are still scarce. Therefore, this study compared the effectiveness of a self-help app to an established face-to-face CBT intervention for panic and agoraphobia. METHOD:The present study conducts a post hoc comparison of two independent RCTs examining participants with panic disorder and/or agoraphobia. Interventions in both studies were based on the same CBT manual. Study 1 (n = 138) included face-to-face CBT; Study 2 addressed the effects of a digital self-help intervention (n = 57). Main outcomes comprised symptoms of both panic disorder and agoraphobia, depressive symptoms and agoraphobic avoidance. Data were analysed using linear mixed models in intent-to-treat and completer data sets. RESULTS:Linear mixed models showed that face-to-face treatment was superior to app treatment in reducing panic and agoraphobic symptoms (R2 = 0.32), depressive symptoms (R2 = 0.24) and agoraphobic avoidance (R2 = 0.12 and 0.15). Dropout rates did not differ significantly, and both interventions demonstrated high levels of adherence. DISCUSSION:Although a smartphone-based CBT intervention was effective in reducing symptoms of panic and agoraphobia, its efficacy was significantly below the effects of the same intervention delivered in face-to-face format. Thus, digital interventions might be most suitable within a stepped-care approach or to bridge waiting times for psychotherapy.

OBJECTIVES:Individuals suffering from cancer have a heightened risk of suicide; thus, understanding suicide-related thoughts and behaviors is key to identifying vulnerable patients. The interpersonal theory of suicide (IPTS) provides a comprehensive framework for examining suicide risk factors and has been validated across a range of samples. This study aimed to evaluate the applicability of IPTS in a group of female cancer patients. METHODS:This study was registered with the German Clinical Trials Register (DRKS00020477; registered on June 30, 2020). In this study, we tested three major hypotheses formulated by the IPTS, using a sample of 199 female cancer patients. RESULTS:As predicted by the IPTS, heightened levels of thwarted belongingness (TB) and perceived burdensomeness (PB) were indicative of elevated levels of passive suicidal ideation (SI). Furthermore, the interaction of TB, PB, and hopelessness was predictive of active SI. However, contrary to theoretical assumptions, the findings indicate that an increased fear of death was associated with higher suicidal intent. LIMITATIONS:The cross-sectional design curtails the affirmation of hypotheses pertaining to causality. Rather than considering a measure of hopelessness specifically related to PB and TB, a general measure was employed. Additionally, the recruitment phase of the study coincided with the onset of the global SARS-CoV-2 virus pandemic, which might have impacted the results. CONCLUSIONS:Even though the three hypotheses were only partially verified, the IPTS provides a beneficial framework for health professionals who are caring for patients with cancer. Longitudinal studies are encouraged to further validate the theory and bolster its application in understanding suicidal behavior.

The conscious engagement with neutral and symptom-related bodily signals (i.e., interoceptive sensibility) is an important transdiagnostic factor whose assessment remains challenging. In two studies, we examined the psychometric properties and the validity of the German Interoceptive Sensitivity and Attention Questionnaire (ISAQ) assessing two convenience samples (N = 365 and N = 254), adults at risk for rosacea (N = 376) and 44 outpatients with pathological illness anxiety compared to 40 controls. Confirmatory factor analyses indicated the structure of the German ISAQ is best represented by the 3-factor model of the original version (F1: sensitivity to neutral bodily sensations, F2: attention to unpleasant bodily sensations, and F3: difficulty disengaging from unpleasant bodily sensations) with an acceptable model fit after consideration of modification indices. Reliability was acceptable for F1 and F2, but poor for F3. Higher correlations of F1 with measures of functional and of F2/F3 with measures of dysfunctional body focus indicated validity. Measurement invariance to the Dutch original was partially met. Persons with illness anxiety scored significantly higher in all ISAQ subscales. Comparable to the original, the German ISAQ is a valid instrument to assess neutral and negative body perception. The third subscale should be interpreted cautiously.

OBJECTIVE:The purpose of this meta-analysis is to give an overview of the relationships between positive and negative metacognitions (PMC, NMC) with health anxiety and pathological safety seeking and avoidant behavior (SSB, AB). METHOD:The preregistered systematic literature screening included following data bases: MEDLINE, PsycINFO, PSYNDEX, PubMed, The Cochrane Library, Web of Science, ProQuest Dissertations & Theses, and The German National Library. The studies were evaluated based on predefined eligibility criteria (i.e., data for PMC/NMC and health anxiety and/ or SSB/AB from adult samples, assessed with validated inventories and presented in English or German language) and risk of bias categories. Correlation coefficients were aggregated with random effect models. Publication biases were estimated with contour enhanced funnel plots and outlier analyses. RESULTS:23 studies (N = 9229) were included in the meta-analysis. Most studies assessed health anxiety in analogue samples. A significant medium effect was found for PMC and health anxiety (r = .36, p < 0.0001, 95% CI:.29 ≤ r ≤ .43), whereas for NMC the effect was large (r = .52, p < 0.0001, 95% CI:.46 ≤ r ≤ .58). For the relationship with SSB the results revealed a moderate effect for PMC (r = 0.31, p = .004; 95%-CI: 0.19 ≤ r ≤ 0.42) and a small effect for NMC (r = .25, p = .02, 95% CI:.05 ≤ r ≤ .43). No study assessed AB. DISCUSSION:Metacognitions are a significant pathological factor in health anxiety, with particularly strong association with NMC. PMC might be of special interest for health anxiety and SSB compared to other psychopathologies. Heterogeneity, missing clinical samples and studies on AB limit generalizability. Future research should further explore the role of metacognitions in health anxiety and focus on the relation with pathological SSB and AB.