The relationship of hypochondriasis to anxiety disorders

Specific phobia of illness: search for a new subtype

Specific phobia of illness makes its appearance in DSM-IV as a new diagnostic subtype, separate from hypochondriasis. A review of the literature indicates that, while there is some support for this new category, studies have not as yet been done that could provide validation. Illness phobia appears to be a significant problem; it is prevalent in the general population and is associated with distress and impairment, including interference with medical care. It appears to be associated with older age, physical illness, and female gender. Group comparisons are needed showing that persons with this phobia can be distinguished from hypochondriasis on the basis of these and other demographic and illness features. We outline a research agenda for demonstrating this separation.

Obsessive-compulsive symptoms in patients with panic disorder

Comorbidity studies have shown an important association between panic disorder (PD) and obsessive-compulsive disorder (OCD). The aim of the current study was to evaluate the prevalence of obsessive-compulsive symptoms (OCS) and OCD in patients with PD. Forty-eight consecutive PD cases (DSM-IV diagnostic criteria) referred to a Brazilian university hospital clinic were studied. The Yale Brown Obsessive Compulsive scale (Y-BOCS) checklist was used to identify the OCS. Subclinical OCD was considered when subjects met all but one DSM-IV criteria for OCD (symptoms did not cause significant distress and interference, did not last more than 1 hour per day, or were not considered excessive or irrational), and OCS when only the criterion for presence of obsessions or compulsions was met. Twenty-nine (60.4%) of the 48 patients evaluated (19 men and 29 women) had at least one OCS: nine (18.8%) had mild OCS, 11 (22.9%) had subclinical OCD, and nine (18.8%) had comorbid OCD. Therefore, 41.7% of the patients had either clinical or subclinical OCD. OCS occurred more frequently in women and, in 70.4% of the cases, preceded the onset of PD. Our results suggest that it is important to evaluate systematically the co-occurrence of OCS in patients with PD, due to the considerable overlap found in symptoms, which may have therapeutic implications. As panic symptoms are usually the main complaint, OCS are often found only when directly investigated.

A systematic review of the epidemiology of somatisation disorder and hypochondriasis

BACKGROUND

This paper reviews current knowledge regarding the prevalence and associated features of somatisation disorder and hypochondriasis in population-based and primary care samples.

METHOD

A systematic review of the literature, which used a standardised definition of somatisation disorder or hypochondriasis and which examined the characteristics and associated features of these disorders in population-based samples or primary care settings.

RESULTS

In population-based studies the prevalence of somatisation disorder and hypochondriasis was too low to examine associated features reliably. In studies using abridged criteria, a clear female predominance was not found in either disorder; there was a consistent relationship with few years of education. There was a close relationship with anxiety and depressive disorders, with a linear relationship between numbers of somatic and other symptoms of distress in several studies, including longitudinal studies. No studies showed that these symptom clusters fulfil the criteria of characteristic onset, course and prognosis required to merit the status of discrete psychiatric disorders.

CONCLUSIONS

On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required.

Blood-injury related phobic avoidance as predictor of nonresponse to pharmacotherapy in panic disorder with agoraphobia

BACKGROUND

Several factors have been investigated as possible predictors of nonresponse to pharmacotherapy in Panic Disorder (PD) patients. In 1995 a study was published by Slaap et al. in this journal that found high Blood-Injury phobia scores on the Marks and Matthews Fear Questionnaire were predictive for a worse treatment-outcome for drug treatment in PD.

METHODS

The present paper describes a replication study with 61 PD patients, by means of a retrospective chart analysis, who were assessed at baseline and after 12 weeks of SSRI-treatment. Nonresponse was defined as still having panic attacks. Response was defined as absence of panic attacks and/or a reduction of at least 50% on the FQ Agoraphobia subscale.

RESULTS

Twenty (32%) patients were nonresponders. Nonresponders had a higher score on the FQ Blood-Injury subscale more often (55%) than responders (19.5%), significant at P=0.008. These results fully support the findings of Slaap et al. Implications of these findings are further discussed.

LIMITATIONS

Limitations of this study are the retrospective design, and the absence of other psycho-physiological parameters of the specific blood-injury phobic complex.

CONCLUSIONS

However, it is tentatively concluded that the presence of comorbid blood-injury related phobic symptoms negatively affects treatment for panic disorder and agoraphobia.

Panic Disorder and Suicide Attempt in the National Comorbidity Survey

Clinical and some epidemiological data conflict concerning the likelihood of suicide attempt in individuals with panic disorder (PD). The purpose of this study was to illuminate the panic disorder-suicide attempt association in the National Comorbidity Survey (NCS; R. C. Kessler et al., 1994). Specifically, suicide attempt histories of those 5,872 respondents answering "yes" or "no" to the suicide attempt question were regressed against lifetime diagnostic histories. Lifetime PD history, in the presence of other disorders, was unrelated to elevated risk of suicide attempt and did not account for additional variance. PD respondents who had made a suicide attempt were characterized by Comorbidity. Epidemiological respondents with lifetime histories of PD alone are not at heightened risk for self-reported suicide attempt.

Sobre o transtorno de pânico e a hipocondria: uma revisão

Introdução/Objetivos: A hipocondria é associada a diversos transtornos de ansiedade, sobretudo ao transtorno de pânico (TP). Estima-se que 50% a 70% dos pacientes com TP tenham sintomas hipocondríacos, e que 13% a 17 % dos hipocondríacos tenham TP associado. O presente estudo teve como objetivo revisar a literatura sobre as relações clínicas, fenomenológicas, cognitivas e psicodinâmicas entre o TP e a hipocondria, além de discutir aspectos conceituais e critérios diagnósticos. Métodos: A busca de artigos foi feita pelo sistema Medline entre 1990 e 2001, utilizando-se, como palavras-chave, transtorno de pânico, agorafobia, hipocondria e preocupações hipocondríacas. Resultados: Considera-se que há comorbidade com hipocondria no TP quando as preocupações com saúde não se restringem a sintomas das crises de pânico. Apesar de geralmente consideradas secundárias, vários pacientes com TP apresentam, antes da primeira crise, manifestações hipocondríacas que podem ser consideradas prodrômicas. A ansiedade pode gerar, num círculo vicioso, preocupações excessivas com saúde, auto-observação seletiva e antecipação do pior. Apesar do viés catastrófico comum, no TP sintomas autonômicos aumentam rapidamente até culminar num ataque, a catástrofe temida é iminente, com comportamentos de esquiva e busca imediata de socorro. Na hipocondria, temem-se doenças mais insidiosas, predominam comportamentos de hipervigilância e busca de reafirmação, as crenças são mais disfuncionais, é pior a relação médico-paciente e maior o foco de sensações erroneamente interpretadas catastroficamente. O medo patológico da morte e a alexitimia estariam presentes nos dois quadros. Conclusão: A sobreposição clínica entre TP/agorafobia e hipocondria é relevante, mas não completa. A relação entre os dois quadros é complexa e possivelmente bidirecional, um aumentando a vulnerabilidade ao outro. Há diferenças fenomenológicas identificáveis e relevantes, com implicações diagnósticas e terapêuticas.

Hypochondriasis and fear of death

Although fear of death has been linked to hypochondriasis, the relationship of this fear to the disorder has received little study. To address this deficiency, we administered a fear of death scale along with measures of hypochondriasis, including the Whiteley Index and Somatic Symptom Inventory, to 162 general medical outpatients. Partial correlations, controlling for age, between the fear of death scale and both the Whiteley Index and Somatic Symptom Inventory were strongly positive. A factor analysis of the fear of death scale yielded three dimensions-fear of dying, loss of meaning, and fear of separation-that were also highly correlated with hypochondriasis. Fear of death and hypochondriasis showed comparable relationships to age and gender as well as to personality dimensions measured by the NEO Five-Factor Inventory. Fear of death appears to be an integral part of hypochondriasis. Its presence lends support to three models of hypochondriasis-the perceptual, existential, and interpersonal-that correspond to the dimensions of fear of death.

Specific phobia of illness in the community

This study evaluated the prevalence, risk factors and morbidity associated with specific phobia of illness. Subjects were from a random, community telephone survey of 500 persons age 40 to 65 who lived in Johnson County, Iowa, USA. Forty-three subjects reported that illness fears substantially bothered them personally or affected their medical care, work, or social life. Twenty-one of these subjects could be contacted and agreed to a semistructured interview designed to diagnose specific phobia of illness and screen for other common psychiatric disorders. Based on the interview, 10 subjects met the criteria for specific phobia of illness, 10 for major depressive disorder, 5 for obsessive-compulsive disorder, 5 for generalized anxiety disorder, 4 for hypochondriasis, 4 for panic disorder and 4 for specific phobia other than illness. Assuming subjects not interviewed were similar to subjects who were, the community prevalence of specific phobia of illness is 4.0%. Among the 10 subjects with specific phobia of illness, 7 had prior negative experiences with illness and 8 had comorbid Axis I disorders. The phobia interfered with medical care as well as social functioning for many subjects. These results suggest a prevalence rate and risk factors that will be useful for additional studies of illness phobia.

The significance of the concept of obsessive-compulsive spectrum disorder to the treatment of chronic nonmalignant pain

The concept of an obsessive-compulsive spectrum of disorders has become useful. This article reviews what has been learned about these conditions (especially in the last few years), and how this information may be helpful to clinicians and researchers who work with patients with chronic nonmalignant pain.

Psychopathological correlates of anxiety sensitivity: evidence from clinical interviews and self-report measures

Most research on anxiety sensitivity (AS) and its relation to psychopathology has examined the Anxiety Sensitivity Index (ASI) in various clinical samples. The present study was the first to investigate psychopathological correlates of AS using self-report measures, the anxiety, somatoform, and substance use disorders sections of the Structured Clinical Interview for the DSM-IV (SCID), and open-ended interview questions about the subjective meaning and origins of AS. A college student sample (N=317) was used for the correlational analysis, and subsamples of high-AS (n=44) and low-AS (n=41) participants completed the interviews. Despite having an ASI score (Mean=35.0) that was equivalent to that observed in panic disorder samples, the screening questions in the clinical interview indicated that only 55% of high-AS participants had panic attacks and the diagnostic assessment indicated that only 30% met criteria for an anxiety disorder. Several findings suggested that AS, at least as measured by the ASI, was strongly related to anxiety disorder symptoms and diagnoses, although there was substantial variation within the anxiety disorder classifications. There was also evidence that AS might extend to a broader catastrophic style concerning bodily symptoms and health that go beyond anxiety symptoms per se. The subjective meaning of AS derived from the interview data stressed the need for a formal, structured interview of AS.

Course of hypochondriasis in an international primary care study

Hypochondriasis is frequently defined as a chronic condition distinct from anxiety and depressive disorders. Consecutive primary care attenders (n=25,916) were screened using the General Health Questionnaire and a stratified random sample (n=5447) completed a baseline diagnostic assessment. All patients with significant psychiatric symptoms and a random sample of remaining patients (n=3201) were asked to complete a follow-up diagnostic assessment 12 months later. Of patients meeting an abridged definition of hypochondriasis at baseline, 18% continued to do so at follow-up and an additional 16% continued to report hypochondriacal worries. 45% of those with hypochondriasis at follow-up also met criteria for DSM-IV anxiety or depressive disorder. Follow-up anxiety or depressive disorder was significantly associated with both onset and persistence of hypochondriasis. Hypochondriasis is moderately stable over time. The clear distinction between hypochondriasis and anxiety/depressive disorders suggested by ICD-10 and DSM-IV may be difficult to accomplish in practice.

Hypochondriacal Concerns: Management Through Understanding

The medically unexplained complaint is often a symptom of hypochondriacal concerns. Patients with hypochondriasis may be managed with either naive realism or consideration of morbid categorization or via dimensional assessment of illness beliefs and behaviors. Naive realism will foster focus somatization and promote regression as well as lead to needless tests and treatments. Attention to categorical entities such a major depression or anxiety disorders will alert the clinician to comorbid psychiatric disorders that respond to traditional psychiatric treatments. Finally, by assessing the domains of illness behaviors such as disease conviction, beliefs in organic versus psychological causes, and denial, the clinician can document and then confront abnormal cognitive schema that revolve around somatic concerns that are a proxy for psychosocial difficulties.

Correlates of hypochondriasis in a nonclinical population

Because few community surveys of hypochondriasis have been completed, little is known about the epidemiology of this disorder outside of clinical populations. To address this deficiency, the authors obtained information about hypochondriasis and pertinent characteristics from a group of first-degree relatives of hypochondriacal and nonhypochondriacal probands who participated in a family study. In addition to psychiatric diagnoses, the authors elicited information on demographic variables, medical history, impairment in functioning, psychiatric comorbidity, psychiatric symptoms, personality traits, and childhood experiences. The authors identified hypochondriasis in 7.7% of the relatives. These relatives had a high rate of comorbid anxiety, depressive, and somatoform disorders. They also reported substantial physical and psychological impairment, including diminished work performance and disability. In addition, these relatives reported greater utilization of health care but less satisfaction with that care. These relatives showed most of the same characteristics found in earlier studies of hypochondriacal patients.