Hypochondriacal fears and beliefs in agoraphobia

The clinical inadequacy of the DSM-5 classification of somatic symptom and related disorders: an alternative trans-diagnostic model

The Diagnostic and Statistical of Mental Disorders, Fifth Edition (DSM-5) somatic symptom and related disorders chapter has a limited clinical utility. In addition to the problems that the single diagnostic rubrics and the deletion of the diagnosis of hypochondriasis entail, there are 2 major ambiguities: (1) the use of the term "somatic symptoms" reflects an ill-defined concept of somatization and (2) abnormal illness behavior is included in all diagnostic rubrics, but it is never conceptually defined. In the present review of the literature, we will attempt to approach the clinical issue from a different angle, by introducing the trans-diagnostic viewpoint of illness behavior and propose an alternative clinimetric classification system, based on the Diagnostic Criteria for Psychosomatic Research.

Psychological correlates of vasovagal versus medically unexplained syncope

OBJECTIVE

Psychiatric morbidity is quite common in vasovagal syncope (VVS), but findings are sometimes contradictory. Among patients with suspected VVS, up to 40% has a negative response to Head-Up Tilt test (HUT), the cause of syncope remaining unexplained (US). The authors evaluated and compared the psychological and psychosomatic profile in patients with positive (VVS) and negative HUT (US).

METHOD

A consecutive series of 67 patients with suspected VVS underwent HUT: 45 patients had a positive HUT, 22 negative. They were evaluated by means of observer- and self-rated measures.

RESULTS

Of the total sample, 95.5% had at least one Diagnostic and Statistical Manual of Mental Disorders diagnosis or one psychosomatic syndrome, such as specific and social phobias, illness denial and demoralization. Comparing VVS and US patients, no statistical differences on diagnoses' frequencies were found. However, the US group had significantly poorer health habits, lower levels of well-being and higher psychological distress. They also reported to be more anxious, depressed and hostile. VVS patients were significantly more blood and social phobic than US patients.

CONCLUSION

Despite similar and remarkable observer-rated psychopathology, US patients reported higher self-perceived psychological distress than VVS patients. Psychological evaluation of patients undergoing HUT should incorporate both clinical and subclinical methods to better address syncope management.

Intolerance of uncertainty, hypochondriacal concerns, obsessive-compulsive symptoms, and worry

Intolerance of uncertainty (IU) has been found to be involved in several anxiety disorders, including generalized anxiety disorder and obsessive-compulsive disorder (OCD). Few studies have examined the role of IU in health anxiety (HA)/hypochondriacal concerns (HC). We conducted two studies exploring the associations between IU and HA/HC. The first study included undergraduates (n = 114) and indicated an association between IU and several HA/HC indices. When controlling for neuroticism, worry about illness was the single index of HA/HC that remained associated with IU. In the second study among bereaved adults (n = 126), IU was associated with one index of HA/HC but not when neuroticism and anxiety sensitivity were controlled. In both studies, IU was found to be more strongly associated with OCD symptoms and worry than with HA/HC.

Health anxiety and fear of fear in panic disorder and agoraphobia vs. social phobia: a prospective longitudinal study

BACKGROUND

This study is aimed to evaluate the role of two vulnerability factors, health anxiety and fear of fear, in the prediction of the onset of panic disorder/agoraphobia (PDA) relative to a comparison anxiety disorder.

METHODS

Young women, aged between 18 and 24 years, were investigated at baseline and, 17 months later, using the Anxiety Disorders Interview Schedule-Lifetime and measures of health anxiety and fear of bodily sensations (subscale disease phobia of the Whiteley Index, and total score of the Body Sensations Questionnaire). First, 22 women with current PDA were compared to 81 women with current social phobia and 1,283 controls. Second, 24 women with an incidence of PDA were compared to 60 women with an incidence of social phobia and 1,036 controls.

RESULTS

Multiple logistic regression analyses adjusted for history of physical diseases, somatic symptoms, and other psychological disorders revealed that (a) fear of bodily sensations was elevated for women with PDA vs. controls as well as women with social phobia, and (b) health anxiety (and history of physical diseases) was elevated in women who developed PDA vs. controls and vs. women who developed social phobia.

CONCLUSIONS

These results suggest that health anxiety, as well as history of physical diseases, may be specific vulnerability factors for the onset of PDA relative to social phobia. Whereas fear of bodily sensations was not found to be a risk factor for the onset of panic disorder/agoraphobia, it was a specific marker of existing PDA relative to social phobia.

Reexamining the domain of hypochondriasis: comparing the Illness Attitudes Scale to other approaches

The present study examined utility of the Illness Attitudes Scale (IAS; [Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger Publishers]) in a non-clinical college sample (N=235). Relationships among five recently identified IAS dimensions (fear of illness and pain, symptom effects, treatment experience, disease conviction, and health habits) and self-report measures of several anxiety-related constructs (health anxiety, body vigilance, intolerance of uncertainty, anxiety sensitivity, and non-specific anxiety symptoms) were examined. In addition, this study investigated the incremental validity of the IAS dimensions in predicting medical utilization. The fear of illness and pain dimension and the symptom effects dimension consistently shared stronger relations with the anxiety-related constructs compared to the other three IAS dimensions. The symptom effects dimension, the disease conviction dimension, and the health habits dimension showed incremental validity over the anxiety-related constructs in predicting medical utilization. Implications for the IAS and future conceptualizations of HC are discussed.

Agoraphobia is a disease: a tribute to Sir Martin Roth

The evidence which has accumulated on the course of agoraphobia challenges the DSM view that phobic avoidance is secondary to panic attacks. In particular, a longitudinal study by Wittchen et al. indicates that agoraphobia, as a diagnostic category, is frequently independent of panic disorder and panic attacks, is unlikely to remit spontaneously and entails compromised quality of life. A staging system of agoraphobia is presented. Panic may ensue in the longitudinal development of agoraphobia, as well as of other anxiety disorders, and be conceptualized as a potential outcome in the course of anxiety, phobias and hypochondriasis as more than a specific disease entity. These recent research findings confirm the clinical observations and phenomenological research of Sir Martin Roth (1917-2006) and call for a reassessment of the concept of neurosis.

The moderating role of health fear on the relation between smoking status and panic symptoms among adolescents

The present study examined the moderating role of health fear on the concurrent relation between smoking status and panic attack symptoms among 249 adolescents (132 females, M(age)=14.86 years). As hypothesized, youth high in health fear reported elevations in panic attack symptoms, whereas this relation was relatively weak among those low in health fear. Importantly, these associations were significant after controlling for age, gender, negative affectivity, and anxiety sensitivity. Also as expected, health fear did not moderate the association between smoking status and depressive symptoms, supporting model specificity. Results are discussed in terms of implications for the panic-smoking association among youth.

Psychological Factors Affecting Medical Condition: A New Proposal for DSM-V

The DSM category of "psychological factors affecting medical condition" had virtually no impact on clinical practice. However, several clinically relevant psychosomatic syndromes have been described in the literature: disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood. These syndromes, in addition to the DSM definition of hypochondriasis, can yield clinical specification in the category of "psychological factors affecting medical condition" and eliminate the need for the highly criticized DSM classification of somatoform disorders. This new classification is supported by a growing body of research evidence and is in line with psychosomatic medicine as a recognized subspecialty.

Prodromal stage of major depression

AIM

The aim of this review was to survey the available literature on prodromal symptoms of unipolar major depression.

METHODS

Both a computerized (Medline) and a manual search of the literature were performed.

RESULTS

In a substantial proportion of patients with depression a prodromal phase can be identified. There is a relationship between residual and prodromal symptomatology (the rollback phenomenon).

CONCLUSIONS

Appraisal of prodromal phase of major depression has important implications as to pathophysiological models of disease and relapse prevention. It may allow a staging system of depressive illness that may yield more enduring results in the therapeutic efforts.

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.

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.

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.

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.

Personality and psychopathology in patients with temporomandibular joint pain-dysfunction syndrome. A controlled investigation

OBJECTIVE

Our aim was to deepen the understanding of the psychosomatic aspects of temporomandibular joint (TMJ) pain dysfunction syndrome. Patients affected by this syndrome were compared with both healthy subjects and psychiatric patients, using both self-report and physician-scored psychological measures.

METHODS

Three sex- and age-matched groups were recruited: a TMJ group (n = 32), a healthy group (n = 22) and a psychiatric group (n = 22). The psychiatric group consisted of outpatients diagnosed as having a DSM-IV anxiety or depressive disorder of mild to moderate severity. Psychometric assessment included the Minnesota Multiphasic Personality Inventory (MMPI) and the Hamilton Anxiety Rating Scale (HARS).

RESULTS

Psychiatric patients scored higher than both the comparison groups on all but one of the MMPI scales; the majority of the differences were significant or approached significance. TMJ patients scored higher than healthy controls on the Hs (hypochondriasis; p< or =0.01), Hy (hysteria; p< or =0.01) and D (depression; p< or =0.05) scales. Psychiatric patients scored higher than TMJ patients on the HARS psychic anxiety subscale (p< or =0.05), while TMJ patients scored higher than psychiatric patients on the somatic anxiety subscale (p< or = 0.05).

CONCLUSIONS

Certain personality characteristics were associated with TMJ dysfunction. However, further longitudinal studies should be performed to properly assess causal relationships. Despite signs of neuroticism, anxiety and depression, patients with TMJ dysfunction differed from anxious and depressed patients. While the latter displayed a higher level of psychopathology, each group was characterised by a distinct pattern of anxiety symptoms. In addition, a substantial proportion of TMJ patients had little awareness of their inner states and emotions.

Hypochondriasis and its relationship to obsessive-compulsive disorder

Hypochondriasis is a heterogeneous disorder. This was well demonstrated in the study by Kellner et al, which showed that patients with high levels of disease fear tended to be more anxious or phobic, whereas patients with high levels of disease conviction tended to have more and more severe somatic symptoms. Little comorbidity exists to support the statement that hypochondriasis is an obsessive-compulsive spectrum disorder. Although patients exist whose hypochondriac concerns are identical in quality to the intrusive thoughts of patients with OCD, as a group, patients with hypochondriasis do not share a comorbidity profile comparable with that of patients with OCD. The data support a closer relationship between hypochondriasis and somatization disorder than between hypochondriasis and OCD. The family history data is limited by the lack of adequate studies. Using comparable methods of the family history approach, Black's study reported a higher frequency of GAD but not OCD among the relatives of OCD patients--a finding similar to what Noyes found among the relatives of hypochondriac patients; however, using the direct interview method, somatization disorder was the only statistically more common disorder, among relatives of female hypochondriac patients. Therefore, although the parallel in overlap with GAD is suggestive of a commonality between OCD, GAD, and hypochondriasis, the finding of a greater frequency of somatization disorder leans against the hypothesis that hypochondriasis is best considered an OCD spectrum disorder. The pharmacologic treatment data are the one type of biologic evidence that supports a bridge to OCD. The pharmacologic studies suggest that for patients with general hypochondriasis, TCAs are not effective and that higher dosages and longer trials of the SRIs are needed. These pharmacologic observations are comparable with the ones made for patients with OCD but dissimilar to the observations made for depression. The benefit of imipramine among patients with illness phobia must be assessed in placebo-controlled trials among illness phobics and among hypochondriacs. Even more valuable would be a direct comparison of a TCA (e.g., imipramine or desipramine) and a selective SRI (e.g., fluoxetine) to determine whether the response to selective SRIs is greater. Although the pharmacologic data are compelling in supporting the hypothesis that hypochondriasis is an obsessive-compulsive spectrum disorder, the comorbidity data are equally compelling in dispelling that hypothesis. Perhaps future studies clarify the subtypes of hypochondriasis, be they "phobic, obsessive, and depressive," "chronic and episodic," "early onset versus late onset" or some other as yet undetermined subtype. Such clarification may be aided by better instruments to assess the obsessive-compulsive and hypochondria spectrums within individuals and families and by neuropsychological or pharmacologic challenge and neuroimaging studies.

Anxiety sensitivity mediates the relationships between childhood learning experiences and elevated hypochondriacal concerns in young adulthood

OBJECTIVE

the present study investigated childhood learning experiences potentially associated with the development of elevated hypochondriacal concerns in a non-clinical young adult sample, and examined the possible mediating roles of anxiety sensitivity (i.e., fear of anxiety-related symptoms) and trait anxiety (i.e., frequency of anxiety symptoms) in explaining these relationships.

METHOD

197 university students participated in a retrospective assessment of their childhood instrumental (i.e., parental reinforcement) and vicarious (i.e., parental modeling) learning experiences with respect to arousal-reactive (e.g., dizziness) and arousal-non-reactive (e.g., lumps) bodily symptoms, respectively. Childhood learning experiences were assessed using a revised version of the Learning History Questionnaire (LHQ), anxiety sensitivity levels with the Anxiety Sensitivity Index (ASI), trait anxiety levels with the State-Trait Anxiety Inventory-Trait (STAI-T) scale, and degree of hypochondriacal concerns with the Illness Attitudes Scale (IAS)-Total score.

RESULTS

consistent with earlier findings [Watt MC, Stewart SH, Cox BJ. A retrospective study of the learning history origins of anxiety sensitivity. Behav Res Ther 1998; 36: 505-525.], elevated anxiety sensitivity levels were associated with increased instrumental and vicarious learning experiences related to both arousal-reactive and arousal-non-reactive bodily symptoms. Similarly, individuals with elevated hypochondriacal concerns also reported both more instrumental and vicarious learning experiences around bodily symptoms than did students with lower levels of such concerns. However, contrary to the hypothesis, the childhood learning experiences related to hypochondriacal concerns were not specific to arousal-non-reactive symptoms, but instead involved parental reinforcement and modeling of bodily symptoms in general (arousal-reactive and -non-reactive symptoms alike). Anxiety sensitivity, but not trait anxiety, partially mediated the relationships between childhood learning experiences and elevated hypochondriacal concerns in young adulthood.

CONCLUSIONS

elevated anxiety sensitivity appears to be a risk factor for the development of hypochondriasis when learning experiences have involved both arousal-reactive and arousal-non-reactive bodily symptoms.

Recognition and acute management of patients with panic attacks in the emergency department

Patients with panic attacks commonly present to emergency departments. If the disorder is identified early, intervention can be begun, even during the evaluation phase. Effective therapies significantly improve these patients' health and quality of life.

Illness Attitudes Scale dimensions and their associations with anxiety-related constructs in a nonclinical sample

The Illness Attitudes Scale (IAS) is a self-rated measure that consists of nine subscales designed to assess fears, attitudes and beliefs associated with hypochondriacal concerns and abnormal illness behavior [Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger; Kellner, R. (1987). Abridged manual of the Illness Attitudes Scale. Department of Psychiatry, School of Medicine, University of New Mexico]. The purposes of the present study were to explore the hierarchical factor structure of the IAS in a nonclinical sample of young adult volunteers and to examine the relations of each illness attitudes dimension to a set of anxiety-related measures. One-hundred and ninety-seven undergraduate university students (156 F, 41 M; mean age = 21.9 years) completed the IAS as well as measures of anxiety sensitivity, trait anxiety and panic attack history. The results of principal components analyses with oblique (Oblimin) rotation suggested that the IAS is best conceptualized as a four-factor measure at the lower order level (with lower-order dimensions tapping illness-related Fears, Behavior, Beliefs and Effects, respectively), and a unifactorial measure at the higher-order level (i.e. higher-order dimension tapping General Hypochondriacal Concerns). The factor structure overlapped to some degree with the scoring of the IAS proposed by Kellner (1986, 1987), as well as with the factor structures identified in previously-tested clinical and nonclinical samples [Ferguson, E. & Daniel, E. (1995). The Illness Attitudes Scale (IAS): a psychometric evaluation on a nonclinical population. Personality and Individual Differences, 18, 463-469; Hadjistavropoulos, H. D. & Asmundson, G. J. G. (1998). Factor analytic investigation of the Illness Attitudes Scale in a chronic pain sample. Behaviour Research and Therapy, 36, 1185-1195; Hadjistavropoulos, H. D., Frombach, I. & Asmundson, G. J. G. (in press). Exploratory and confirmatory factor analytic investigations of the Illness Attitudes Scale in a nonclinical sample. Behaviour Research and Therapy; Speckens, A. E., Spinhoven, P., Sloekers, P. P. A., Bolk, J. H. & van Hemert, A. M. (1996). A validation study of the Whitley Index, the Illness Attitude Scales and the Somatosensory Amplification Scale in general medical and general practice patients. Journal of Psychosomatic Research, 40, 95-104]. The Fears, Beliefs and Effects lower-order factors and the General Hypochondriacal Concerns higher-order factor, were shown to be strongly associated with anxiety sensitivity, even after accounting for trait anxiety and panic history. Implications for understanding the high degree of comorbidity between the diagnoses of panic disorder and hypochondriasis, as well as future research directions for exploring the utility of various IAS dimensions in predicting responses to lab-based bodily symptom-induction procedures, are discussed.

Subclinical symptoms of panic disorder: new insights into pathophysiology and treatment

The aim of this review was to survey the available literature on prodromal and residual symptoms of panic disorder. Both a computerized (Medline) and a manual search of the literature were performed. In a substantial proportion of patients with panic disorder with agoraphobia a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon). Appraisal of subclinical symptomatology in panic disorder has important implications as to the pathophysiological model of disease, its conceptualization and treatment.

Illness attitudes and coping process in subjects with panic attacks

Personality disorders may affect comorbidity and health care utilization in subjects with panic attacks. The purpose of this study was to identify differences in illness attitudes and behaviors, and in coping strategies in community-based subjects with panic attacks compared with controls. A community-based sample of 97 subjects meeting DSM-III-R criteria and matched controls completed the Illness Behavior Questionnaire, the Illness Attitude Scale, and the Ways of Coping Checklist. The panic group reported less healthy attitudes and behaviors. Although there were no panic-control differences in use of positive coping strategies, the panic group reported more use of negative coping strategies. The differences in illness attitudes and behaviors, and in coping strategies, may explain comorbidity and care-seeking behavior in subjects with panic attacks.

Health concerns in patients with obsessive-compulsive disorder

In the present study, individuals with obsessive-compulsive disorder (OCD) who also had excessive health concerns (n = 56) were compared with OCD individuals without such concerns (n = 343) regarding their OCD symptom severity, types of obsessions and compulsions, insight into the irrationality of their obsessions, and prevalence of generalized anxiety disorder. While the presence of health concerns did not affect the severity of OCD symptoms, the groups differed with respect to the types of symptoms displayed: those with health concerns had more somatic and harm obsessions, and checking compulsions: whereas those without such concerns had more contamination obsessions and washing compulsions. The insight of both groups ranged from poor to excellent, yet the number of individuals with poor insight was greater among those with health concerns than those without. Generalized anxiety disorder was also more prevalent among OCD individuals with excessive health concerns.

The Illness Attitude Scales in chest pain patients: a study of psychometric properties

The main aim of the study was to assess the factorial structure of the Illness Attitude Scales (IAS). The study population comprised 199 patients referred to cardiological out-patient investigation because of chest pain. The factor analysis revealed three factors of the IAS. Accordingly, we found three subscales, interpreted as health anxiety (HA), illness behavior (IB), and health habits (HH). The internal consistency of the subscales, measured by Cronbach's alpha coefficient, were 0.92, 0.80, and 0.49, respectively. The HA and IB scores were significantly intercorrelated (r = 0.39, p < 0.001), but HH was not significantly correlated with either HA or IB. The HA and IB subscales discriminated between patients with and without panic disorder. The results support previous findings, namely that the IAS comprise two subscales with psychometrically sound properties. Correlational analysis indicated validity of the two subscales. Further studies are needed to confirm the validity.

The relationship of hypochondriasis to anxiety disorders

There is evidence from the literature of phenomenological overlap between hypochondriasis and several anxiety disorders, including specific phobia, panic disorder with agoraphobia, generalized anxiety disorder, and obsessive-compulsive disorder. Even though the boundaries of these disorders are specifically addressed in the DSM-IV criteria, there is evidence of anxiety and phobic symptoms among hypochondriacal patients and hypochondriacal concerns among patients with these various anxiety disorders. Beyond that there appears to be considerable shared comorbidity. However, the data remain limited and few direct comparisons have been made between hypochondriacal and anxious patients belonging to particular diagnostic categories. Subtypes of hypochondriasis may exist. In fact, the clearest link would seem to be between the illness phobia subtype and other phobic disorders, although this subgroup has had little study. Thus, hypochondriasis is distinct from the anxiety disorders but, because of phenomenological similarities and extensive comorbidity, consideration should be given to classifying it among them.

Predictors of 1-year outcome for patients with panic disorder

The course of panic disorder (PD) is often prolonged, but factors that affect the social outcome have not yet been made clear. The aim of this study was to find predictors of outcome for patients with PD. The subjects were 65 outpatients (28 men and 37 women) with PD (DSM-III-R) who were treated at our hospital for more than 1 year. The factors affecting 1-year outcome were evaluated by multiple regression analysis. We found that the following were predictors of poor social outcome in PD: (1) severe agoraphobia at the first psychiatric examination and (2) long duration of illness before the first psychiatric consultation. Furthermore, the complication of hypochondriacal symptoms predicted a poor outcome for PD. Early attention to agoraphobia and hypochondriasis is essential for the treatment of PD, and early introduction to psychiatric treatment is recommended.

Additional findings on the association between anxiety sensitivity and hypochondriacal concerns: examination of patients with major depression

Hypochondriacal concerns ranging from disease phobias to bodily preoccupations are common among patients with panic disorder. In a previous study of patients with panic disorder, we found that, of a number of symptom dimensions examined, anxiety sensitivity was the strongest predictor of hypochondriacal concerns. This finding has been the topic of subsequent debate in the anxiety literature, with concerns raised whether true hypochondriacal concerns were confounded with typical panic-related concerns. To clarify this issue, we now report on the association between anxiety sensitivity and hypochondriacal concerns in 100 patients with major depression and no history of panic disorder. Consistent with our previous study, we found that of the symptoms examined--anxiety sensitivity, depressed mood, anxious mood, somatic symptoms, and anger/hostility--anxiety sensitivity was the strongest predictor of hypochondriacal concerns. Findings are discussed in relation to the role of catastrophic interpretations of somatic symptoms in depression, panic disorder, and hypochondriasis.

A family study of hypochondriasis

To examine the diagnostic validity of hypochondriasis, we undertook a preliminary family study. Nineteen probands with and 24 without DSM-III-R hypochondriasis were identified among outpatients attending a general medicine clinic. Seventy-two first-degree relatives of hypochondriasis probands and 97 relatives of control probands were personally interviewed with the use of the Structured Clinical Interview for DSM-IV. These relatives also completed self-administered measures of hypochondriasis, psychological and somatic symptoms, and personality traits. No increase in the rate of hypochondriasis was found among the relatives of hypochondriasis probands compared with the relatives of control probands. With respect to other mental disorders, only somatization disorder was more frequent among the hypochondriacal relatives. These relatives also scored higher on measures of hostility, antagonism, and dissatisfaction with medical care. The findings of this study suggest that hypochondriasis may not be an independent disorder but a variable feature of other psychopathology, one that may include somatization disorder.

Hypochondriasis and illness phobia in panic-agoraphobic patients

In a sample of 131 patients with panic disorder, we explored both the presence of DSM-III-R criteria for hypochondriasis and the occurrence of illness phobia before the onset of panic disorder. To explore further the possible relationship between hypochondriacal features and panic-agoraphobic syndrome, we compared patients both with and without current hypochondriasis and then patients both with and without illness phobia before the onset of panic disorder. Finally, we investigated the relationship between premorbid phobic-anxious traits and hypochondriasis during panic disorder. No differences were found between patients with and without hypochondriasis, either in terms of clinical features or in the course of panic disorder. Patients with illness phobia before the onset of panic disorder reported higher levels of anticipatory anxiety in nonagoraphobic situations and more depersonalization and derealization during panic attacks, and they met our definition of phobic-anxious temperament more frequently than the rest of the sample. This would suggest that illness phobia before the onset of panic disorder may be viewed either as a separate disorder, a prodrome, or a mild, early-onset form of panic disorder without full-blown attacks. Although patients with premorbid illness phobia are more likely to develop hypochondriasis after the onset of panic disorder, approximately 40% of them do not; therefore, illness phobia should not be considered the only factor that influences the development of hypochondriasis during panic disorder.

Hypochondriacal concerns in depressed outpatients

The relationship between hypochondriacal concerns, as assessed by the Illness Attitude Scales, and depressive symptoms was examined in a sample of 100 drug-free outpatients with major depressive disorder. These patients were treated with fluoxetine for 8 weeks, and the effect of treatment on hypochondriacal symptoms was examined. All patients were administered the Structured Clinical Interview for DSM-III-R, the Hamilton Depression Rating Scale, the Symptom Questionnaire, and the Personality Disorders Questionnaire-Revised. We found little relationship between severity of depressive symptoms and hypochondriacal concerns. Measures of anxiety, somatic symptoms, and psychological distress were more consistently related to these concerns. Similarly, patients with either histrionic personality disorder or a lifetime history of panic disorder had greater hypochondriacal concerns than patients without these diagnoses. After open treatment with fluoxetine, the degree of hypochondriacal concerns showed statistically significant decreases, which were only partly related to the degree of change in depression and anxiety severity. Our findings suggest that the presence of hypochondriacal concerns among depressed outpatients is more closely related to the presence of anxiety than depressive symptoms. The relatively small impact of an acute course of antidepressant treatment on hypochondriacal concerns in our sample suggests that these concerns may be enduring characteristics modulated only to a limited extent by short term pharmacological alterations of affective state.

Hypochondriacal fears and beliefs in obsessive-compulsive disorder

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.

Comorbidity of anxiety disorders and hypochondriasis considering different diagnostic systems

The influence of different hierarchical guidelines in various classification systems on the diagnosis of anxiety disorders and hypochondriasis was investigated. Using a semistructured polydiagnostic interview (including DSM-III, DSM-III-R, and the 1987 draft version of ICD-10), lifetime diagnoses were determined in B2 outpatients with a DSM-III-R anxiety disorder. In all diagnostic systems, half of our patients exhibited the descriptive features of hypochondriasis. As demonstrated, the formulation of restrictive hierarchical rules--as in DSM-III--contributes to the concept of "primary" hypochondriasis, while secondary hypochondriasis remains underdiagnosed. Concordance rates for hypochondriasis were high between DSM-III-R and ICD-10, but not with DSM-III. Although hypochondriasis showed a strong association with the clinical course of panic disorder (PD), it could not be explained as a consequence of greater illness severity of PD with agoraphobia (AP). Our data underline the conceptualization of hypochondriasis as a phenomenologically homogeneous diagnostic category that may be differentiated from comorbid psychiatric conditions.

Respiratory disorders as a possible predisposing factor for panic disorder

150 consecutive anxiety patients completed a specially designed questionnaire which asked for the occurrence of respiratory and other somatic disorders before the onset of their anxiety disorder. The sample was divided into 82 panic disorder patients and 68 other anxiety patients serving as controls. Panic disorder patients had a significantly higher prevalence of respiratory diseases before the onset of their anxiety disorder than controls (42.7 vs. 16.2%). This higher prevalence was mainly due to a higher prevalence of bronchitis (26.8 vs. 8.8%). Differences in numbers of respiratory disorders mentioned appeared not to result from a tendency to hypochondria.

Bottlenecks in the diagnosis of hypochondriasis

This review deals with diagnostic problems in DSM-III-R hypochondriasis. A first category of problems is directly connected with the definition of hypochondriasis. The following topics are discussed: the distinction between hypochondriasis and hypochondriacal attitude, the personality aspects of hypochondriasis, and the role of medical findings in the diagnosis. This is followed by a discussion of problems as to the distinction between hypochondriasis and related disorders. This concerns the status of hypochondriasis as a primary or secondary disorder in depression and the relationship with anxiety disorders (especially panic disorder and obsessive-compulsive disorder [OCD]) and the somatization disorder. The DSM-III-R classification of hypochondriasis as a somatoform disorder is disputed. A third category of problems lies in the measurement of hypochondriasis. The scope and quality of the most frequently used questionnaires for measuring hypochondriasis are poor. In research, on the basis of a single questionnaire and without due consideration of medical findings, the diagnosis of hypochondriasis is applied too soon. Finally, it is briefly indicated that the lack of diagnostic clarity affects the way in which the patient is approached in clinical practice.

Neurocirculatory asthenia: a reassessment using modern psychosomatic criteria

The purpose of this study was to assess the prevalence of mental illness and to evaluate the quality of life of patients with neurocirculatory asthenia. A consecutive series of 80 patients who satisfied the diagnostic criteria developed by Kannel et al. for neurocirculatory asthenia was included in this study. Patients underwent a psychiatric diagnostic research interview and extensive psychometric evaluation, with both observer and self-rated scales for depression, anxiety, phobic symptoms, quality of life and abnormal illness behavior. In 47 patients (59%), a psychiatric diagnosis (mainly an anxiety disorder) antedated the onset of neurocirculatory asthenia, which was thus defined as secondary, also because cardiorespiratory symptoms were part of the mental symptoms. In the remaining 33 patients (41%) neurocirculatory asthenia was the primary disorder. Patients with secondary neurocirculatory asthenia reported significantly higher levels of anxiety, depression, social phobia, abnormal illness behavior and an impaired quality of life compared with patients with primary neurocirculatory asthenia. This latter did not significantly differ in these variables (except for depression) from healthy control subjects matched for sociodemographic variables. At a 1-year follow-up, patients with primary neurocirculatory asthenia had a much better prognosis than those with secondary neurocirculatory asthenia. The results indicate the feasibility of the primary/secondary distinction based on the time of onset of mental and cardiorespiratory symptoms in neurocirculatory asthenia. Since only about one quarter of the patients were found to suffer from decreased energy and fatigue according to specified criteria, the terms neurocirculatory asthenia and effort syndrome should probably be discarded.

Psychiatric comorbidity among patients with hypochondriasis

The purpose of this study was to determine the nature and extent of comorbidity among patients with DSM-III-R hypochondriasis and to examine the relationships between this disorder and coexisting psychiatric illness. For this purpose, patients seen in a general medicine clinic were screened using measures of hypochondriacal attitudes and somatic symptoms. Those scoring above an established cutoff were given a structured diagnostic interview. In this manner, 50 patients who met DSM-III-R criteria for hypochondriasis and 50 age- and sex-matched controls were identified. The presence of other psychiatric disorders (current and past) was determined by means of the same diagnostic interview. More hypochondriacal subjects (62.0%) had lifetime comorbidity than did controls (30.0%). Major depression, the most frequent comorbid disturbance, was usually current and most often had an onset after that of hypochondriasis. Panic disorder with agoraphobia, the most frequent anxiety disorder, was also current but often began before or at the same time as hypochondriasis. Few subjects met criteria for somatization disorder but a third qualified for a subsyndromal form of this disorder. The data show that, in medical outpatients with hypochondriasis, mood and anxiety disorders frequently coexist. This comorbidity is subject to varying interpretations including overlap of symptom criteria, treatment-seeking bias, and the possibility that hypochondriasis predisposes to or causes the comorbid disorder, as seems likely in the case of depression. In some instances hypochondriasis may be an associated feature of another illness.

Diagnosis and treatments of hypochondriacal syndromes

There are controversies in the literature about the diagnosis and most appropriate treatment of hypochondriasis. The author offers guidelines for diagnosis of hypochondriacal syndromes that have not been adequately dealt with in the literature and discusses the choice of treatments.

Hypochondriacal fears and beliefs, anxiety, and somatisation

Four self-rating scales of hypochondriasis and the Symptom Checklist-90 were administered to 100 general practice (GP) patients and matched non-psychotic psychiatric out-patients. In a stepwise linear regression, self-rated somatic symptoms and anxiety predicted hypochondriacal fears and beliefs; self-rated depression did not appear as a predictor. There were differences between males and females and between psychiatric patients and GP patients in the associations of these constructs. These results varied in part with the scale of hypochondriasis used. Various scales of hypochondriasis appear to measure different features of the hypochondriasis syndrome. Fear of disease (disease phobia) was associated with anxiety, whereas a false belief of having a disease (disease conviction) was associated more with somatic symptoms.

Panic disorder and hypochondriacal fears and beliefs

The purpose of this study was to examine correlates of hypochondriacal fears and beliefs in patients with panic disorder (PD) (n = 54). They were evaluated using the structured diagnostic interviews for axis I and axis II disorders (SCID-UP-R and SCID-II). They were administered the Illness Attitudes Scales (IAS) as a measure of hypochondriacal fears and beliefs, the Hopkins Symptom Checklist 90 (HSCL), and the Fear Questionnaire (FQ). One half of the patients rated themselves as having substantial hypochondriacal fears and beliefs. The sample was divided into groups of patients seeking predominantly treatment or relief from symptoms (treatment-oriented), and those who were searching for a cause of their illness (explanation-seeking): the latter had significantly more hypochondriacal concerns. Avoidant, histrionic, and borderline personalities were more common in the hypochondriacal group. The results of several analyses suggest that patients with PD who are also agoraphobic, fear physical disease more and have more false beliefs of having a disease than PD patients without agoraphobia.

A comparison of patients with illness phobia and panic disorder

Fourteen subjects with illness phobia, a subtype of hypochondriasis, were compared with an equal number of subjects with panic disorder who had been matched for age and sex. The illness phobic subjects differed from panic subjects in not having spontaneous panic attacks or agoraphobic symptoms, the characteristic features of panic disorder. The onset of illness phobia was related to experience with illness in half the subjects. Half of the illness phobic subjects also had family histories of anxiety disorders. The results suggest that illness phobia is distinct from panic disorder and that it is a disorder in which environmental and genetic factors are etiologically important.

Characterological traits of recovered patients with panic disorder and agoraphobia

Three self-rating personality inventories were administered to 33 patients who had recovered from panic disorder associated with agoraphobia and to 33 healthy subjects matched for sociodemographic variables. The personality inventories comprised the Tridimensional Personality Questionnaire (TPQ), which provides three major dimensions (novelty seeking, harm avoidance and reward dependence), the Anxiety Sensitivity Index (ASI) and the Emotional Inhibition Scale (EIS). Agoraphobic patients reported significantly more TPQ harm avoidance and anxiety sensitivity than controls. Although these findings might have been influenced by residual anxiety symptoms in panic-free patients and could also apply to patients with other anxiety disorders, they suggest that harm avoidance and anxiety sensitivity may be risk factors for developing agoraphobia and panic disorder. There may be overlap between this characterologic cluster and prodromal symptoms of panic disorder with agoraphobia, such as anxiety, phobias and hypochondriasis.

Psychiatric aspects of chest pain in the emergency department

We estimate that a third of the patients who present to the ED with chest pain have a current psychiatric disorder and that psychiatric disorders among chest pain patients are associated with a high rate of ED utilization for chest pain evaluations. Physicians in the ED recognize only a small fraction of the psychiatric disorders, so appropriate treatment or referral may be infrequent. The proportion of chest pain patients with CAD who also have a psychiatric disorder may be in the range of 20% to 30%, justifying careful assessment of psychiatric disorders in CAD patients. We conclude that the psychiatric aspects of chest pain are sufficiently prevalent, clinically significant, and a contributor to unnecessarily high utilization of medical services. We call for clinical research to address these questions by outlining three areas of study that will advance our knowledge and care of the patient with chest pain.

Mechanisms of change of panic attacks with exposure treatment of agoraphobia

In vivo exposure homework was applied to a consecutive series of 30 outpatients suffering from DSM-IIIR panic disorder with agoraphobia. Assessment of the characteristics of panic attacks (the prodromal phase immediately preceding the attack, acute peak anxiety, and the residual phase immediately afterwards) was done by an independent rater before treatment, after six sessions and at the end of therapy (12 sessions). Twenty-five of the 30 patients completed treatment. All of them still reported panic attacks after six sessions, even though the characteristics of panic partially improved. At the end of therapy, panic attacks disappeared in 21 of the 25 patients (84%) and these gains were maintained to 1 year follow-up thereafter by the majority (81%) of subjects.

Imipramine an effective treatment for illness phobia

Ten subjects with illness phobia were treated with imipramine for 8 weeks. All of the eight subjects who remained on the drug for 4 weeks or more reported at least moderate improvement. Overstimulatory reactions occurred in four subjects causing two to discontinue medication. Imipramine appears to be a potentially useful treatment for this subtype of hypochondriasis.

Hypochondriacal fears and beliefs in pregnancy

Illness attitudes were evaluated in 26 pregnant women and 26 control subjects matched for sociodemographic variables, by means of a self-rating scale, on 3 different occasions. For each trimester of pregnancy, women displayed more hypochondriacal fears and beliefs and conviction of disease (disease phobia) than normal controls. In the third trimester, they also reported more fear of dying and bodily preoccupations. The findings should alert physicians to ask their pregnant patients whether they are preoccupied with fear of dying, or are concerned that they suffer from an undiagnosed physical illness, or dread a specific illness such as cancer or heart disease. Hypochondriacal fears and beliefs are liable to affect well-being and the health attitudes of pregnant women. If properly recognized, they may effectively be treated.