Hypochondriacal concerns and somatic symptoms in patients with chronic airflow obstruction

In order to explore hypochondriacal concerns in patients with Chronic Airflow Obstruction (CAO) the authors administered the Illness Attitude Scales and the somatization, anxiety, depression and anger-hostility scales of the Hopkins Symptom Checklist to 50 patients with CAO and to matched family practice patients. Somatic symptoms were significantly correlated with fears of disease and hypochondriacal concerns in family practice patients, but were unrelated in CAO. Patients with CAO, although more anxious, depressed and with more severe somatic symptoms than family practice patients, had fewer hypochondriacal concerns. In this respect patients with CAO were unlike any other group previously studied.     

Illness coping strategies and hypochondriacal traits among medical inpatients

The Illness Coping Strategies scale (ICS) is an 18-Likert-item scale developed to examine illness appraisal and coping by medical patients more comprehensively than instruments which screen for hypochondriacal traits in this population. This study has examined the association of hypochondriacal traits with illness coping strategies addressed by the ICS among 101 randomly selected inpatients drawn from a general medicine unit of a teaching general hospital. Despite the exclusion of patients with substance abuse or organic mental disorder, or referral for psychiatric consultations, hypochondriacal traits were prevalent in this inpatient sample. Five factor-derived subscales of the ICS (disease vigilance, limit activity, overresponsiveness, self-treatment and obsessive worry) were extracted, and internal consistency and test-retest reliabilities were determined. Multiple regression analysis on a composite measure of hypochondriasis revealed that the five ICS factor scales accounted for 26 percent of the variance. Patients with a high hypochondriacal index had associated high scores on symptom vigilance, limit activity and obsessive worry subscales, suggesting that these illness coping strategies may represent an important aspect of hypochondriacal illness presentation. The self-treatment subscale appeared to act as a suppressor variable, contributing to the prediction of the hypochondriacal index by extracting self treatment aspects from the other illness coping factors. Illness coping responses found to be associated with hypochondriacal traits in this study were rather passive strategies which promoted increased vigilance and concern about symptoms while providing few opportunities to reduce uncertainty regarding health status.     

Relationship between hypochondriacal concerns and personality dimensions and traits in a military population

Our aim was to examine the relationship between personality dimensions and hypochondriacal concerns and somatic symptoms in a military population. The Schedule of Nonadaptive and Adaptive Personality along with measures of hypochondriacal concerns and somatic symptoms were administered to 602 military veterans who had been on active duty during the 1991 Gulf War. Factor analyses identified six separable dimensions-two of hypochondriacal concerns, two of somatic symptoms, and two of possible mechanisms of symptom generation-for study. Multiple regression models determined the proportion of variation in these measures of somatic distress explained by personality scales. Personality measures explained between 26% and 38% of the variance in hypochondriacal concerns and somatic symptoms, and Negative Temperament accounted for most of this. Moderately strong positive correlations were observed between trait scales Mistrust, Low Self-Esteem, and Eccentric Perceptions and the various measures of somatic distress. Thus, when Negative Temperament was taken into account, few significant correlations between personality measures and hypochondriacal concerns or somatic symptoms remained. Negative temperament or neuroticism is strongly associated with hypochondriacal concerns. Important features of hypochondriasis and somatic distress appear to lie within the domain of personality. It remains for future research to show whether negative temperament is a vulnerability factor for hypochondriasis or hypochondriasis is itself a personality disorder.     

Transient hypochondriasis

Consecutive visitors to a general medicine outpatient clinic were screened with a hypochondriasis questionnaire. Two thirds (n = 41) of those exceeding a preestablished cutoff met the criteria for DSM-III-R hypochondriasis when given a structured diagnostic interview, while the other third (n = 22) did not. The latter group showed significant decreases in their hypochondriasis questionnaire scores over a 3-week interval. They had less psychiatric disorder and more medical morbidity than the DSM-III-R hypochondriacs. They also viewed their medical care more positively, and their physicians considered them less hypochondriacal. The transiently hypochondriacal group was also compared with a random sample (n = 75) of the patients below the cutoff on the screening instrument. They had more Axis I disorder, more personality disorder, reported higher levels of somatosensory amplification, and more medical disorder. The differences in psychiatric comorbidity and amplification persist when medical morbidity is controlled for by matching and analysis of covariance. This is consistent with the hypotheses that among patients confronted with a medical illness, those with personality disorder and those who are sensitive to somatic sensation are more likely to develop transient hypochondriasis.     

Differentiating hypochondriasis from panic disorder

Hypochondriasis and panic disorder are both characterized by prevalent health anxieties and illness beliefs. Therefore, the question as to whether they represent distinct nosological entities has been raised. This study examines how clinical characteristics can be used to differentiate both disorders, taking the possibility of mixed symptomatologies (comorbidity) into account. We compared 46 patients with hypochondriasis, 45 with panic disorder, and 21 with comorbid hypochondriasis plus panic disorder. While panic patients had more comorbidity with agoraphobia, hypochondriasis was more closely associated with somatization. Patients with panic disorder were less pathological than hypochondriacal patients on all subscales of the Whiteley Index (WI) and the Illness Attitude Scales (IAS) except for illness behavior. These differences were independent of somatization. Patients with hypochondriasis plus panic had higher levels of anxiety, more somatization, more general psychopathology and a trend towards increased health care utilization. Clinicians were able to distinguish between patient groups based upon the tendency of hypochondriacal patients to demand unnecessary medical treatments. These results confirm that hypochondriasis and panic disorder are distinguishable clinical conditions, characterized by generally more psychopathology and distress in hypochondriasis.     

Psychiatric comorbidity in DSM-III-R hypochondriasis.

Forty-two DSM-III-R hypochondriacs from a general medical clinic were compared with a random sample of 76 outpatients from the same setting. Patients completed a research battery that included a structured diagnostic interview (Diagnostic Interview Schedule) and self-report questionnaires to measure personality disorder caseness, functional impairment, and hypochondriacal symptoms. Psychiatric morbidity in the hypochondriacal sample significantly exceeded that of the comparison sample. Hypochondriacs had twice as many lifetime Axis I diagnoses, twice as many Diagnostic Interview Schedule symptoms, and three times the level of personality disorder caseness as the comparison group. Of the hypochondriacal sample, 88% had one or more additional Axis I disorders, the overlap being greatest with depressive and anxiety disorders. One fifth of the hypochondriacs had somatization disorder, but the two conditions appeared to be phenomenologically distinct. Hypochondriacal patients with coexisting anxiety and/or depressive disorder (secondary hypochondriasis) did not differ greatly from hypochondriacal patients without these comorbid conditions (primary hypochondriasis). Because the nature of hypochondriasis remains unclear and requires further study, we suggest that its nosologic status not be altered in DSM-IV.     

Hypochondriacal fears and beliefs in medical and law students

We administered two validated scales of hypochondriacal concerns (the Illness Behavior Questionnaire and the Illness Attitude Scales) to 60 medical students and matched law students. Medical students took more precautions about their health and attended more to somatic symptoms, but the prevalence of hypochondriacal fears, beliefs, and attitudes did not differ significantly between the two groups. Five students (8.3%) in each group scored in the range of patients with hypochondriacal neurosis. Most of the students were free of these concerns. The prevalence of hypochondriacal concerns in medical students was substantially lower than the previously reported incidence over four years of study; this supports the previous observation that most of these reactions are short lived.     

A structured diagnostic interview for hypochondriasis. A proposed criterion standard.

We developed a structured diagnostic interview for DSM-III-R hypochondriasis (SDIH) that is the first such clinician-administered instrument. The SDIH was administered to 88 general medical outpatients who scored above a predetermined cutoff on a hypochondriacal symptom questionnaire, and to 100 comparison patients randomly chosen from among those below the cutoff. Using the joint assessment method, interrater agreement on the DSM-III-R diagnostic criteria was 88% to 97% and agreement on the diagnosis was 96%. Concurrent validity was suggested by a significant correlation between the interview and the primary care physicians' ratings of hypochondriasis. A measure of external validity was demonstrated in that several clinical characteristics thought to be ancillary features of hypochondriasis were significantly more prevalent in interview-positive patients than in interview-negative patients. Finally, the SDIH appeared to have discriminant validity in that patients diagnosed as hypochondriacal had several other clinical features that distinguished them from the patients who scored above the cutoff on hypochondriacal symptomatology, but failed to be diagnosed as hypochondriacal with the SDIH.     

The prevalence of hypochondriasis in medical outpatients

Summary Forty-one DSM-III-R hypochondriacs were obtained by screening consecutive visitors to a general medical clinic and compared with 76 patients randomly chosen from the same setting. They completed a research battery consisting of a structured diagnostic interview (DIS) and self-report questionnaires to measure hypochondriacal symptoms and functional impairment. The criterion standard for diagnosing hypochondriasis was a structured interview of demonstrated reliability and validity. The six-month prevalence of DSM-III-R hypochondriasis was estimated to be between 4.2% and 6.3% of consecutive attenders who met the inclusion criterion of having visited the same physician before. This rate was somewhat lower than that found for generalized anxiety disorder and comparable to that of alcohol abuse. The hypochondriacal patients did not differ significantly from the comparison random sample in sociodemographic risk factors except that they were significantly more likely to be Black. Hypochondriacal symptomatology was similar in males and females; and in those over 65 and those under 65. Over a three-week interval, hypochondriacal symptoms remained stable, and hypochondriacal patients had significantly higher levels of long-term disability than did the comparison patients.This investigation was supported by research grant MH40487 from the National Institute of Mental Health     

The relation between hypochondriasis and age

OBJECTIVE: This study examined the relation between hypochondriasis and age while controlling for the possible confounding influences of medical morbidity, social isolation, and other psychiatric disorder. METHOD: Consecutive patients attending a general medical clinic on randomly selected days were screened with a hypochondriasis self-report questionnaire. Those whose scores exceeded a preestablished cutoff level and a random sample of those who scored below it completed a research battery consisting of self-report questionnaires and structured interviews for DSM-III-R diagnoses of hypochondriasis and other axis I disorders. The patients' medical records were audited, and their physicians completed questionnaires about them. The 60 patients who met the DSM-III-R criteria for hypochondriasis at interview constituted the study group, and 100 patients randomly chosen from among those who scored below the cutoff for hypochondriasis constituted the comparison group. RESULTS: The hypochondriacal group was not older than the comparison group. Hypochondriacal patients aged 65 years and over did not differ significantly from younger hypochondriacal patients in hypochondriacal attitudes, somatization, tendency to amplify bodily sensation, or global assessment of their overall health, even though their aggregate medical morbidity was greater. The elderly hypochondriacal patients had higher levels of disability, but this appeared to be attributable to their medical status rather than to any increase in hypochondriasis. Within the comparison sample, subjects aged 65 years and over were not more hypochondriacal than those under 65 years of age. CONCLUSIONS: Hypochondriasis is found to some degree in all patients and appears to be unrelated to age.     

Hypochondriacal concerns and attitudes toward illness in males and females.

OBJECTIVE: To review the published studies on the sex distribution of hypochondriasis, and to examine sex differences in hypochondriacal concerns and in attitudes toward illness. METHOD: The Illness Attitude Scales, Factors 2 and 3 of the Whiteley Index and the Symptom Checklist-90 (SCL-90) were administered to fifty randomly-selected female family practice patients ages eighteen to sixty-five, and to male patients matched by age in decades. From a pool of 130 consecutive nonpsychotic psychiatric outpatients, fifty females and fifty males were matched with the family practice patients. RESULTS: Although females rated themselves as more depressed than males in both groups, there were no significant differences between the sexes in hypochondriacal fears and beliefs. Psychiatric male patients reported the most adverse effects of bodily symptoms on work and leisure. There were no other significant differences between the sexes in any of the other attitudes toward illness or symptoms. Hypochondriacal concerns were more common in the psychiatric patients than in the family practice patients of both sexes. CONCLUSION: The review of published studies on the sex distribution of hypochondriasis suggests that disease phobia is more common in females, except for the cardiophobic syndrome, which is more common in males. The other reported differences are inconsistent and appear to be caused by referral biases, varying diagnostic criteria, and cultural factors. In our study, we found no substantial differences between males and females in hypochondriacal concerns and attitudes toward illness.     

Hypochondriacal concerns and somatization in panic disorder

To clarify the relationship between panic disorder and the symptoms of hypochondriasis and somatization, we evaluated these symptoms and diagnoses in patients attending an Anxiety Disorders Clinic. Structured clinical interviews, self-report measures, and symptom diaries were used to assess 21 patients with panic disorder, 23 patients with social phobia, and 22 control subjects with no psychiatric disorders. Ten of the patients with panic disorder (48%) also met DSM-IV criteria for hypochondriasis, whereas only one of the patients with social phobia and none of the healthy control subjects met the criteria for this diagnosis. None of the participants met DSM-IV criteria for somatization disorder, even though both anxiety groups reported high levels of somatic symptoms. The panic disorder group reported higher levels of fear about illness and disease conviction and endorsed more somatic symptoms than did the other groups. A higher proportion of panic disorder patients reported previously diagnosed medical conditions (48%) as compared with patients with social phobia (17%) or healthy control subjects (14%). The panic disorder patients with DSM-IV hypochondriasis obtained higher scores on measures of hypochondriacal concerns, somatization, blood–injury phobia, and general anxiety and distress than did the panic disorder patients without hypochondriasis. The results suggest a strong association between panic disorder and hypochondriasis. Depression and Anxiety 6:78–85, 1997. © 1997 Wiley-Liss, Inc.     

Abnormal illness behavior of patients with functional somatic symptoms: relation to psychiatric disorders.

Functional somatic symptoms are highly associated with hypochondriasis, anxiety, and depressive disorders. Despite the absence of an organic disorder, underlying psychological distress of patients with functional somatic symptoms may result in abnormal illness behavior such as inadequate treatment seeking or overuse of medical services. Using the Illness Behavior Questionnaire (IBQ), we examined the illness behavior of Japanese patients visiting a general medicine clinic whose physical symptoms were considered functional. We used the General Health Questionnaire-30 to classify patients with functional somatic symptoms as those with and without psychological distress. Patients with distress (n=35) reported more physical complaints and higher IBQ scores than did patients without distress (n=22). The IBQ profile of patients with psychological distress was identical to that of patients diagnosed with either hypochondriasis or major depression. The illness behavior of patients without psychological distress was indistinguishable from that of patients whose physical symptoms were attributed to organic disease. These results further support the hypothesis that functional somatic symptoms may be associated with hypochondriasis and major depression, the pathology of which may contribute to the development of abnormal illness behavior.     

Depression and hypochondriasis in family practice patients with somatization disorder

The relationships specified in DSM-III between somatization disorder and depression, and somatization disorder and hypochondriasis require further validation and easier methods of detection for use by primary care physicians. The authors investigated hypochondriacal and depressive symptoms in 13 family practice outpatients with somatization disorder. Pain complaints and depressive symptomatology were present in over 75% of this group, while hypochondriacal symptoms were present in 38%. The mean score on the somatization scale of the Hopkins Symptom Check List (HSCL-90) was greater than that reported for any other group. These findings support the separation of somatization disorder and hypochondriasis and suggest the need for better delineation of depressive subtypes in somatization disorder. The somatization scale of the HSCL-90 should be a useful screen for somatization disorder in future research.     

Hypochondriasis: the patient's perspective

OBJECTIVE: The purpose of this investigation was to learn how patients with hypochondriasis view their physicians and medical care. METHOD: To accomplish this, we identified 20 patients with DSM-III-R hypochondriasis and 26 nonhypochondriacal patients from a general medicine clinic. Using a semistructured interview, we obtained information from patients about their recent health problems and medical care. The investigators then reviewed transcribed interviews and assigned comments to a series of categories. RESULTS: Hypochondriacal and non-hypochondriacal patients made equal numbers of positive comments, but hypochondriacal patients made significantly more negative comments about physicians' professional characteristics, characteristics of the patients themselves and total negative comments. Many viewed physicians they had seen as unskilled and uncaring. They indicated that, in many instances, their relationships with physicians had suffered from poor communication and collaboration. CONCLUSION: Since successful management of patients with hypochondriasis rests upon positive relationships, ways must be found to improve the frustrating and costly situation that currently exists.     

Hypochondriacal fears and beliefs in obsessive-compulsive disorder

Savron G, Fava GA, Grandi S, Rafanelli C, Raffi AR, Belluardo P. Hypochondriacal fears and beliefs in obsessive-compulsive disorder. Acta Psychiatr Scand 1996: 93: 345–348. © Munksgaard 1996. The relationship of obsessions and compulsions with hypochondriasis is receiving increasing attention, but has not been substantiated by adequate research. The Illness Attitude Scales (IAS), which identify hypochondriacal patients, were administered to 30 patients with DSM-IV obsessive-compulsive disorder and 30 healthy control subjects matched for sociodemographic variables. All IAS scales were significantly higher in patients with obsessions and compulsions. However, there were no significant differences between patients and controls in the number of subjects whose symptom intensity exceeded a clinical threshold for hypochondriasis and disease phobia. Furthermore, hypochondriacal fears and beliefs were poorly correlated with obsessions and compulsions. The results suggest the presence of mild abnormal illness behaviour in patients with obsessive-compulsive disorder. unlike the situation in patients with panic disorder and depression.     

Pain,anger and illness behaviour

A 52-item Illness Behaviour Questionnaire (I.B.Q.) was administered to 100 patients referred for the management of pain that had not responded adequately to conventional treatment. A comparison group of 40 patients attending rheumatology, radiotherapy, pulmonary, and physiotherapy clinics, that reported pain as a prominent symptom, also completed the I.B.Q. Responses to two items from the questionnaire assessing the frequency and expression of angry feelings were used to classify patients. Patients from the intractable pain group reported an incidence of anger inhibition (53%) significantly higher than that of the comparison group (33%). Within the intractable pain group, patients' reports of the frequency and expression of angry feelings were found to be related to more general aspects of their illness behaviour. Patients who inhibited anger were more likely to have a “psychological” view of their symptoms and to be affectively disturbed. Patients who angered easily were more likely to be hypochondriacal as well as affectively disturbed. The findings of this study indicate that individual differences in illness behaviour must be recognized as influencing observed relationships between pain and anger.     

The correlates of hypochondriasis in depressed patients

Of 100 inpatients with depressive illness, fifty-three had evidence of depressed mood prior to their hypochondriacal symptoms, sixteen had the opposite sequence of development and thirty-one had no hypochondriacal symptoms. Comparisons of the three groups revealed some differences that would suggest a less severe depressed mood in association with hypochondriacal symptoms. Whether hypochondriasis preceded or followed depressed mood did not make any other difference to the total clinical picture. This should not be taken to imply that treatment and prognosis are the same in hypochondriacal and nonhypochondriacal depressions.     

Hypochondriasis. An evaluation of the DSM-III criteria in medical outpatients

We attempted to integrate the DSM-III criteria for hypochondriasis with the clinical literature and derived six positive and two negative diagnostic criteria. Seven of these were assessed in a random sample of 92 medical outpatients by means of a self-report questionnaire, structured interview, and medical record audit. The results are in accord with previous work: there appears to be considerable internal validity and consistency in the syndrome in that disease conviction, disease fear, bodily preoccupation, and somatic symptoms are significantly intercorrelated. The three hypochondriacal attitudes (conviction, fear, and preoccupation) were not statistically related to the number of medical diagnoses in the patients' medical records. Depressive symptoms, as measured by the Beck Depression Inventory, were highly correlated with the other hypochondriacal symptoms. The hypochondriacal syndrome in these patients appears to be consistent with the clinical disorder described in DSM-III.