Hypochondriasis with panic attacks

Frequent attenders in general medical practice in Italy: a preliminary report on clinical variables related to low functioning

BACKGROUND

Frequent attenders (FAs), defined as patients reporting a disproportionate number of visits to general practitioners (GPs), may represent up to one-third of GP patients responsible for a high burden of care not always justified by the severity of the medical condition. The aim of this study was to explore sociodemographic and clinical characteristics of FAs of GP in Italy with particular attention to functional impairment.

METHODS

A total sample of 75 FAs (defined as individuals who had consulted GPs 15 times or more during 2015) of GPs of three primary care centers (Pisa, Livorno, and Lucca) in Italy were enrolled and assessed by sociodemographic scale, Structured Clinical Interview for DSM-5 (SCID-5), global functioning (Global Assessment of Functioning [GAF]), illness behavior and perceived health (Illness Behavior Inventory), and somatic comorbidity (Cumulative Illness Rating Scale).

RESULTS

Most of the sample were females, middle aged, married, or cohabiting, with low levels of education. One-third of FAs was low functioning (LF; GAF score <70), with no differences in the sociodemographic variables. Approximately 70.3% of the patients reported a current SCID diagnosis, in particular, major depressive disorder, somatic symptom disorders, and panic disorder, all being more frequent in LF patients. Half of the patients were taking a psychopharmacological therapy, mostly benzodiazepines (BDZs).

CONCLUSION

Most FAs were female with current medical disorders, and LF. All claimed to be worried about their own health and perceived themselves as more impaired also regarding the health perception and social role. LF patients were, or had been more likely to be under psychopharmacological treatment. FAs seem to constitute a special population that should be carefully evaluated for mental disorders and appropriate treatment.

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.

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.

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.

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.

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.

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.

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.

A retrospective study of the learning history origins of anxiety sensitivity

Anxiety sensitivity (AS; the fear of anxiety-related sensations) has been proposed as a risk factor for the development of panic disorder. The present study involved a conceptual replication of Ehlers' (1993, Behaviour Research and Therapy, 31, 269-278) study on childhood learning experiences and panic attacks, but also extended her work by investigating the relationship between early learning experiences and the development of AS, in a non-clinical sample. A sample of 551 university students participated in a retrospective assessment of their childhood and adolescent instrumental and vicarious learning experiences with respect to somatic symptoms (i.e. anxiety and cold symptoms, respectively) using an expanded version of Ehler's (1993) Learning History Questionnaire. AS levels were assessed using the Anxiety Sensitivity Index, and panic history was obtained using the Panic Attack Questionnaire, Revised. Contrary to hypotheses, the learning experiences of high AS individuals were not found to be specific to anxiety symptoms, but involved parental reinforcement of sick-role behavior related to somatic symptoms in general. High AS subjects reported both more anxiety and cold symptoms prior to age 18 than individuals with lower levels of AS. In addition, both cold and anxiety symptoms elicited more special attention and/or instructions from parents for high AS individuals to take special care of themselves. These findings are contrasted with the results for self-reported panickers who reported more learning experiences (modeling and parental reinforcement) specific to anxiety-related symptoms, than the non-panickers. The results suggest that higher-than-normal levels of AS may arise from learning to catastrophize about the occurrence of bodily symptoms in general, rather than anxiety-related symptoms in particular.

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.

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.

Prodromal symptoms in panic disorder with agoraphobia: a replication study

The majority of 20 patients suffering from panic disorder with agoraphobia reported experiencing agoraphobic avoidance, generalized anxiety, and/or hypochondriacal fears and beliefs before the first panic attack. The results replicated those of a previous investigation and are in accordance with an increasing number of studies concerned with prodromal symptoms, epidemiologic surveys, and analysis of mechanisms of change upon treatment.

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.