The relationship of hypochondriasis to anxiety disorders

Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences

Health anxiety involves excessive worries about one's health along with beliefs one has an illness or may contract a serious disease. Concerning evidence suggests that health anxiety is on the rise in society, possibly further fueled by the COVID-19 pandemic. Recent classification systems acknowledge that impairing health-related worries and beliefs can emerge in early childhood with significant levels of symptoms persisting throughout childhood, and possibly continuous with diagnostic considerations in adulthood. This narrative review summarizes recent research advances in health anxiety in children and adolescents, focusing on various developmental aspects of health anxiety and related concepts in youths. Findings suggest that health anxiety symptoms in young age groups are associated with impairment, distress, and increased healthcare use, as well as substantial comorbidity with mainly other emotional problems and disorders. Furthermore, longitudinal studies suggest that childhood health anxiety can persist across adolescence, perhaps with links to chronic courses in adulthood. The growing literature was further reviewed, thus extending our understanding of early risk factors, including the potential role of exposure to serious illness and transgenerational transmission of health anxiety. Learning more about developmental trajectories will be highly relevant to inform strategies for early detection and prevention. While modified cognitive behavioral therapies in adults are successful in treating health anxiety, specific interventions have not yet been tested in youths. Given substantial overlaps with other psychopathology, it could be important to develop and explore more transdiagnostic and scalable approaches that take advantage of common factors in psychotherapy, while also including a wider perspective on potential familiar maladaptive illness cognitions and behaviors.

Health anxiety symptoms in pediatric obsessive-compulsive disorder: patient characteristics and effect on treatment outcome

The aim was to explore the potential clinical role of health anxiety (HA) symptoms in children and adolescents diagnosed with obsessive-compulsive disorder (OCD). The study investigated differences in demographic and various clinical variables between young people with OCD, with and without HA symptoms, and the effect of HA symptoms on overall OCD treatment outcome. The study sample comprised 269 children and adolescents with OCD (aged 7-17 years) from the large Nordic Long-term OCD Treatment Study. OCD symptoms and severity were assessed with The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), which includes one item regarding HA-like obsessions and one item regarding HA-like compulsions that were used to define the HA group. Several other instruments were used to assess comorbidity and other clinical aspects. All participants were treated with 14 weekly protocolled sessions of exposure-based cognitive behavioral therapy (CBT). HA symptoms were present in 31% of participants. Other anxiety symptoms and comorbid anxiety disorders were more prevalent among those with HA symptoms. These patients also presented with significantly more types of OCD symptoms. HA symptoms were reduced following OCD treatment with CBT and having HA symptoms did not affect CBT outcome. Results suggest that pediatric OCD with HA symptoms is characterized by more anxiety symptoms and a more heterogeneous OCD symptom profile. Standardized CBT seems equally effective in treating child and adolescent OCD with or without HA symptoms.Clinical trials registration: Nordic Long-term Obsessive-Compulsive Disorder Treatment Study: www.controlled-trials.com ; ISRCTN66385119.

Illness Anxiety Disorder: A Case Report and Brief Review of the Literature

Illness anxiety disorder (IAD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) as the preoccupation with having or acquiring a serious illness, in the absence of somatic symptoms (or, if present, symptoms that are only mild in severity). Patients with IAD experience persistent anxiety or fear of having or acquiring a serious illness, which adversely affects their daily life. They remain unsatisfied with their physician’s reassurances to the contrary, mainly because their distress is created by the anxiety of the meaning, significance, and cause of the complaints and not necessarily due to the physical presentations. IAD remains a huge burden on both the health facility and for the managing healthcare provider. In this report, we present the case of a patient with IAD, which has been managed for the past five years with recurrent visits to the physician with no resolution of signs and symptoms. Despite extensive medical workup over this period, which repeatedly showed normal test results, the patient continued to have anxiety over his ill health and complained of recurrent mild somatic symptoms. After his most recent appointment, he got very upset and booked a flight to his home country to have a second opinion to validate his illness. Physicians are encouraged to build a therapeutic alliance with patients with IAD, rather than ordering expensive or unnecessary diagnostic tests or treatment.

Psychopathological Aspects of Somatization in the Works of the Department of Psychiatry of Irkutsk State Medical Institute in the First Half of the 20th Century – from the Origins of the Psychosomatic Medicine to the Present

The article discusses modern problems of dimensional diagnosis of somatoform disorders including the vagueness of the criteria and the lack of reliance on pathogenetic differences in the selection of separate classification categories. An ongoing discussion on the necessity of revision of the boundaries and of “redistribution” of some somatoform disorders into different categories in accordance with their psychopathological relationship is associated with these problems. As a promising change in the diagnostic criteria of the DSM-V classification, the emphasis is shifted to psychological and behavioral characteristics, which is assessed as an actualization of the classical descriptive diagnostics methodology. As a confirmation of the significance of this, an analysis of the psychopathological study of Irkutsk psychiatrists of the first half of the 20th century, devoted to the delusion of obsession, is given. In 1935, the head of the Department of Psychiatry at the Irkutsk Medical Institute V.S. Deryabin and his student I.S. Sumbaev published a scientific work “Delirium of obsession and somatic sensations”. The authors substantiate the intimate relationship of traditionally understood sensual hysterical and ideatorial hypochondriacal mechanisms in the formation of an integral clinical picture of somatoform disorders. The use of descriptive diagnostics many decades before the introduction of ICD-10 proves the pathogenetic unity of hysterical (sensory) and hypochondriacal (ideatorial) formations within the psychosomatic register of disorders and the legitimacy of combining phenomenologically different states into a circle of somatoform disorders.

Association Between Anxiety and Depression and Gastroesophageal Reflux Disease: Results From a Large Cross-sectional Study

Background/Aims

The different clinical manifestations of gastroesophageal reflux disease (GERD) may be influenced by associated psychological factors. We evaluated the psychological status (anxiety and depression) according to each subtype of GERD.

Methods

Subjects who underwent esophagogastroduodenoscopy and completed a symptom questionnaire between January 2008 and December 2011 were analyzed. The subjects were classified into the following groups: erosive reflux disease (ERD), non-erosive reflux disease (NERD), asymptomatic erosive esophagitis (AEE), and controls. Anxiety and depression were assessed using the State-Trait Anxiety Inventory and Beck Depression Inventory, respectively.

Results

We analyzed 19 099 subjects: 16 157 (84.6%), 176 (0.9%), 1398 (7.3%), and 1368 (7.2%) in the control, ERD, NERD, and AEE groups, respectively. Multiple multinomial logistic regression revealed a significant association of increased state (adjusted OR, 1.89; 95% CI, 1.53–2.33) and trait anxiety (adjusted OR, 1.78; 95% CI, 1.34–2.35) and depression (adjusted OR, 2.21; 95% CI, 1.75–2.80) with NERD. ERD group showed a significant association only with state anxiety (adjusted OR, 2.20; 95% CI, 1.27–3.81) and depression (adjusted OR, 2.23; 95% CI, 1.18–4.22). The AEE group, however, did not show any significant association with psychological factors.

Conclusion

This cross-sectional study revealed that anxiety and depression levels were significantly higher in subjects with GERD (notably in the NERD) than in controls.

Health anxiety symptoms in children and adolescents diagnosed with OCD

Health anxiety (HA) is an overlooked area in paediatric research. Little is known about the occurrence of HA symptoms in a child and adolescent psychiatric setting, and there are no age-appropriate diagnostic criteria and only limited number of assessment tools. It is therefore likely that HA is seen as part of obsessive-compulsive disorder (OCD) due to construct overlap and the diagnostic uncertainty of HA in this age group. In the present study, the extent of HA symptoms was investigated in 94 children and adolescents with a primary ICD-10 diagnosis of OCD. Self-reported HA symptoms were assessed using the Childhood Illness Attitude Scales. Clinician-rated OCD symptoms and severity were measured using the Children's Yale Brown Obsessive Compulsive Scale. Information on socio-demographics was obtained from the child's/adolescent's medical record. The distribution of HA symptoms resembled a normal curve shifted to the right compared with a normal population of Danish children, and 30 % presented with high HA symptoms. Chi-squared tests were used to examine the proportion of children and adolescents with high HA symptoms in relation to various clinical characteristics. Clinician-rated illness worries and comorbid anxiety disorder were associated with high self-reported HA symptoms. The results contribute to the understanding of how HA and OCD overlap conceptually in young patients and bring attention to the need for improved recognition of OCD patients dominated by illness worries. Further research in the description of childhood HA is important in order to understand whether HA is a distinct disorder early in life.

Fears, Coping Styles, and Health Behaviors: A Comparison of Patients With Hypochondriasis, Panic Disorder, and Depression

Research into correlates of illness anxiety disorder (formerly hypochondriasis) rarely applies comprehensive assessments of health behavior. Moreover, studies on phenomenological varieties of clinical health anxiety are scarce. We examined health behavior, fear, and acceptance of death and dying, and coping with a hypothetical bodily disease in patients with hypochondriasis, panic disorder, depression, and healthy controls (all groups n = 30) using self-rated questionnaires. ANOVA with Dunnett-T3 post hoc tests revealed no group differences in health behavior. The hypochondriasis and panic disorder groups showed more fear and less acceptance of death and dying than patients with depression and controls. Groups did not differ concerning coping strategies. Patients with hypochondriasis ruminated more when confronted with their most feared rather than another disease. Patients apparently overestimate the danger of a specific disease, but without underestimating their coping abilities. A therapeutic focus on fear of death and dying via cognitive interventions and exposure is recommended.

The Association of Sensory Responsiveness with Somatic Symptoms and Illness Anxiety

BACKGROUND

Somatoform Disorders or Somatic Symptom and Related Disorders are a major public health problem.The pathophysiology underlying these disorders is not yet understood.

PURPOSE

The aim of this study was to explore if sensory responsiveness could contribute to a better understanding of pathophysiological mechanisms underlying two key symptoms of Somatoform Disorders, namely somatic symptoms and illness anxiety.

METHODS

We measured vibrotactile perception thresholds with the HVLab Perception Meter and examined their association with somatic symptoms, illness anxiety and trait anxiety. A sample of 205 volunteers participated in the study.

RESULTS

Sensory responsiveness was neither associated with somatic symptoms (β = -0.01; 95% confidence interval (CI), -0.37, 0.39) nor trait anxiety (β = -0.07; 95% CI, -0.30, 0.07). However, lower vibrotactile perception thresholds were associated with increased scores of the overall illness anxiety scale (β = -0.65; 95% CI, -1.21, -0.14) and its constituent subscale disease conviction (β = -2.07; 95% CI, -3.94, -0.43).

CONCLUSIONS

Our results suggest that increased sensory responsiveness is associated with illness anxiety and hence should be examined further as potential target within the etiopathology of somatoform disorders.

Where does obsessive-compulsive disorder belong in DSM-V?

A reclassification of obsessive-compulsive disorder (OCD) into a new diagnostic category spectrum of "obsessive-compulsive spectrum disorders" (OCSDs) has recently been proposed, with considerable debate, for the forthcoming Diagnostic and Statistical Manual-Fifth Edition (DSM-V). This paper provides a critical analysis of the available empirical data regarding this conceptual and nosological shift. Specifically, we review research on shared commonalities and differences between OCD and the putative OCSDs in relation to their clinical presentation, phenotype, neurobiology, and treatment response. We conclude that a reclassification of OCD into a separate OCSD spectrum is premature and not supported by the currently available data.

Mismanagement of a hypochondriacal patient

Hypochondriasis is a persistent preoccupation that despite appropriate medical evaluations and assurance of patient's physical health, the patient insists on having a serious disease. The case which is discussed in this article is a 39-years-old woman that hospitalized for half of her life and no one can perceive her disorder according to her assertions. The mentioned case is a "difficult patient" with fear of oxygen shortage and being choked (Pnigophobia) which leads to continuous tendency to wear oxygen device even during sleep. There is no benefit in exaggerating her condition for herself so there is no fictitious disorder considered. During the therapy she has been assured that she does not have a serious disease and she has learnt to decrease oxygen intake and breath with his mouth. The point that makes this study different from the others is that most of hypochondriacal patients have a fear of getting HIV, cancers, hepatitis and MS but our patient has phobia of pulmonary embolism.

Comorbidity of fear of progression and anxiety disorders in cancer patients

OBJECTIVE

The relation between fear of progression (FoP) and anxiety disorders remains unclear. Therefore, we investigated the comorbidity between clinical FoP and psychiatric anxiety disorders.

METHOD

In this cross-sectional study, 341 cancer patients undergoing acute inpatient care participated. A structured clinical interview (Structured Clinical Interview for DSM-IV Axis I) was used to identify Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition anxiety disorders and hypochondriasis. Patients completed measures of FoP (Fear of Progression Questionnaire), worries (Penn State Worry Questionnaire, Worry Domains Questionnaire), depression [Patient Health Questionnaire (PHQ): Depression], anxiety (PHQ: General Anxiety Disorder) and somatic symptoms (PHQ: Somatic Symptoms). We cross-tabulated FoP with the presence of anxiety disorders and studied associated variables.

RESULTS

Of all patients studied, 17.6% suffered from an anxiety disorder. With regard to comorbidity, 68.3% suffered neither from clinical FoP nor from any anxiety disorder, 13.4% had not been diagnosed with an anxiety disorder but experienced clinical FoP, and 11.6% only suffered from an anxiety disorder. The remaining 6.7% suffered from FoP that was comorbid with an anxiety disorder. Patients with a pure FoP did not differ from patients with a pure anxiety disorder on nearly all symptom measures. Only a few associations between the comorbidity pattern and sociodemographic and clinical variables emerged.

CONCLUSION

Clinical FoP appears to be a distinct phenomenon. It does not differ from anxiety disorders in its psychological and somatic burdens.

Implicit affective evaluation bias in hypochondriasis: findings from the Affect Misattribution Procedure

Cognitive theories of hypochondriasis (HYP) suggest that catastrophic misinterpretations of benign body sensations are a core feature for the maintenance of the disorder. There is tentative support from an analog sample that the interpretation of illness-related information also involves an implicit affective component. This is the first study to examine this negative affective evaluation bias implicitly in patients with HYP. An adapted version of the Affect Misattribution Procedure (AMP) with illness, symptom and neutral primes was used in 80 patients with HYP, and compared to 83 patients with an anxiety disorder (AD), as well as 90 healthy controls (CG). The HYP group showed significantly more negative affective reactions in illness prime trials, compared to both control groups, as well as more negative implicit evaluations on symptom prime trials, compared to the CG. Significant inverse relationships were observed only between the implicit evaluations of illness words and health anxiety questionnaires. Thus, an implicit negative affective evaluation bias of serious illnesses rather than symptoms is a unique feature of HYP.

Health anxiety, cognitive coping, and emotion regulation: a latent variable approach

BACKGROUND

Health anxiety, the fear or conviction of suffering from a severe disorder, represents a dimensional and multifactorial construct consisting of cognitive, behavioral, affective, and perceptual components. It has recently been proposed that dysfunctional emotion regulation strategies contribute to health anxiety, but the empirical evidence for this claim is sparse.

PURPOSE

The current research was aimed at broadly exploring and clarifying possible relationships between dimensions of health anxiety and cognitive coping and emotion regulation strategies.

METHOD

In two studies with non-clinical samples (n study 1 = 172; n study 2 = 242), health anxiety, cognitive coping, and emotion regulation strategies were assessed using multidimensional self-report measures. Functional (e.g., reappraisal) and dysfunctional (e.g., rumination) cognitive coping and emotion regulation strategies were differentiated.

RESULTS

Using structural equation modeling, the results of Study 1 revealed significant and consistent associations between the dimensions of health anxiety and dysfunctional coping and emotion regulation strategies. Study 2 replicated and extended the main findings of Study 1 by demonstrating that the associations between health anxiety and strategies of coping and emotion regulation were independent of the current level of depressive symptoms.

CONCLUSION

Health anxiety was found to be associated with dysfunctional coping and emotion regulation strategies (e.g., suppression). The positive associations between behavioral dimensions of health anxiety (e.g., seeking reassurance) and dysfunctional coping strategies may suggest that behavioral dimensions of health anxiety serve as a compensatory strategy to overcome difficulties in cognitive coping.

Panic Disorder and Agoraphobia in OCD patients: clinical profile and possible treatment implications

OBJECTIVE

Panic Disorder (PD) and agoraphobia (AG) are frequently comorbid with obsessive-compulsive disorder (OCD), but the correlates of these comorbidities in OCD are fairly unknown. The study aims were to: 1) estimate the prevalence of PD with or without AG (PD), AG without panic (AG) and PD and/or AG (PD/AG) in a large clinical sample of OCD patients and 2) compare the characteristics of individuals with and without these comorbid conditions.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Bivariate analyses were followed by logistic regression models.

RESULTS

The lifetime prevalence of PD was 15.3% (N=153), of AG 4.9% (N=49), and of PD/AG 20.2% (N=202). After logistic regression, hypochondriasis and specific phobia were common correlates of the three study groups. PD comorbidity was also associated with higher levels of anxiety, having children, major depression, bipolar I, generalized anxiety and posttraumatic stress disorders. Other independent correlates of AG were: dysthymia, bipolar II disorder, social phobia, impulsive-compulsive internet use, bulimia nervosa and binge eating disorder. Patients with PD/AG were also more likely to be married and to present high anxiety, separation anxiety disorder, major depression, impulsive-compulsive internet use, generalized anxiety, posttraumatic stress and binge eating disorders.

CONCLUSIONS

Some distinct correlates were obtained for PD and AG in OCD patients, indicating the need for more specific and tailored treatment strategies for individuals with each of these clinical profiles.

Prevalence and quality of anxiety in patients with epilepsy

BACKGROUND

Depression and anxiety are the most frequent psychiatric disorders identified in patients with epilepsy. We aimed to determine the prevalence of state and trait anxiety in patients with epilepsy compared with people without epilepsy.

METHODS

We recruited patients and healthy controls in the outpatient neurology clinic of Kurdistan University of Medical Sciences, Iran, during 2011. Eighty-four patients with epilepsy and 168 healthy persons from relatives of the patients in the case group were recruited and filled out the inventory. The State-Trait Anxiety Inventory (STAI) was used to measure anxiety. After selection of participants and neurological evaluation, all subjects were clinically interviewed at the outpatient clinic of neurology. Data were analyzed using SPSS software, version 16. Fisher's exact and chi-square tests were used for nominal variables, and the t-test was used for anxiety scores.

RESULTS

The average ages of the patients in the case and control groups were 28 and 27.5 years, respectively. State anxiety was significantly higher in patients with epilepsy than in the control group (p=0.042). Also, a higher trait anxiety score was reported in the case group compared with the control group (p=0.009).

CONCLUSION

The rates of both state and trait anxiety were higher in patients in the case group. It appears that anxiety in epilepsy is not just a reaction to a stressful situation, and there may be genetic or temperamental factors that contribute to the relationship between epilepsy and anxiety.

Rasch scalability of the somatosensory amplification scale: a mixture distribution approach

OBJECTIVE

Somatosensory amplification refers to a person's tendency to experience somatic sensations as inappropriately intense and involves hypervigilance concerning bodily sensations. We applied the Somatosensory Amplification Scale (SSAS) in an Internet sample of young adults (N=3031) to test whether the SSAS is Rasch scalable.

METHODS

We applied mixture distribution extensions of the partial credit and rating scale models to identify possible subgroups that use the response set of the SSAS in different ways.

RESULTS

A partial credit model, with two latent classes, showed a superior fit to all other models. Still, one of the SSAS items had to be removed because it showed severe underfit. Overall fit of the remaining items was acceptable, although the differentiation between at least two of the five item categories was questionable in both classes. Class 1 was characterized by a higher SSAS sum score, female gender, more somatic complaints, more anxiety, more psychosocial stress, and slightly higher depressiveness. Further exploratory analyses showed that the three mid categories of the SSAS can be collapsed without a large loss of information.

CONCLUSIONS

Our results show that a shortened version of the SSAS is Rasch scalable but also reveal that there is a lot of room for further improvements of the scale. Based on our results, Item 1 should be removed from the scale and a reduction of the number of response categories is probably warranted.

Health care utilisation in the first year of life among infants of mothers with perinatal depression or anxiety

BACKGROUND

Limited information is available on associations between maternal depression and anxiety and infant health care utilisation.

METHODS

We analysed data from 24 263 infants born between 1998 and 2007 who themselves and their mothers were continuously enrolled for the infant's first year in Kaiser Permanente Northwest. We used maternal depression and anxiety diagnoses during pregnancy and postpartum to categorise infants into two depression and anxiety groups and examined effect modification by timing of diagnosis (pregnancy only, postpartum only, pregnancy and postpartum). Using generalised estimating equations in multivariable log-linear regression, we estimated adjusted risk ratios (RR) between maternal depression and anxiety and well baby visits (<5 and ≥ 5), up to date immunisations (yes/no), sick/emergency visits (<6 and ≥ 6) and infant hospitalisation (any/none).

RESULTS

Infants of mothers with perinatal depression or anxiety were as likely to attend well baby visits and receive immunisations as their counterparts (RR = 1.0 for all). Compared with no depression or anxiety, infants of mothers with prenatal and postpartum depression or anxiety, or postpartum depression or anxiety only were 1.1 to 1.2 times more likely to have ≥ 6 sick/emergency visits. Infants of mothers with postpartum depression only had marginally increased risk of hospitalisation (RR = 1.2 [95% confidence interval 1.0, 1.4]); 70% of diagnoses occurred after the infant's hospitalisation.

CONCLUSIONS

An understanding of the temporality of the associations between maternal depression and anxiety and infant acute care is needed and will guide strategies to decrease maternal mental illness and improve infant care for this population.

Dysfunctional beliefs about symptoms and illness in patients with hypochondriasis

BACKGROUND

The cognitive model and empirical research underline the importance of dysfunctional beliefs about bodily symptoms and illness in health anxiety and hypochondriasis. However, specificity of such beliefs has not yet been adequately demonstrated for patients with hypochondriasis.

OBJECTIVE

This study examined whether dysfunctional beliefs about bodily symptoms and illness are elevated in comparison to patients with anxiety disorders and, therefore, specific for patients with hypochondriasis.

METHOD

Patients with hypochondriasis (n = 38), patients with anxiety disorders (n = 40), and healthy controls (n = 42) completed the Symptom and Outcomes Scale (SOS) measuring participants' estimation of the likelihood of various symptoms being indicative of a particular illness. Additionally, participants' general psychopathology (Brief Symptom Inventory), depressive (Beck Depression Inventory-II), and anxiety symptoms (Beck Anxiety Inventory) were evaluated.

RESULTS

In comparison to patients with anxiety disorders and healthy controls, patients with hypochondriasis estimated bodily symptoms to be more likely an indicator for a catastrophic illness. Patients with anxiety disorders took a middle position between patients with hypochondriasis and healthy controls. Regarding the estimation of the likelihood of symptoms indicating a minor illness, no differences were found between the three groups.

CONCLUSIONS

Dysfunctional beliefs about symptoms and illness are important and specific for patients with hypochondriasis, which is in line with the cognitive model. In order to reduce misinformation about serious illnesses in patients with hypochondriasis, more attention should be paid to psychoeducational strategies.

Hypochondriasis, somatoform disorders, and anxiety disorders: sociodemographic variables, general psychopathology, and naturalistic treatment effects

The question of whether hypochondriasis (HYP) should be considered a somatoform disorder (SFD) or classified as an anxiety disorder (ANX) has recently been raised. To empirically provide information on this issue, we compared patients with HYP (n = 65) with those with other SFDs (n = 94) and those with ANX (n = 224) regarding sociodemographic and biographical variables, general psychopathology, and naturalistic cognitive-behavioral therapy treatment effects. Compared with SFD, patients with HYP were younger and had fewer comorbid affective disorders and less impaired life domains, suggesting a closer connection between HYP and ANX. Regarding cognitive-behavioral therapy treatment effects, all diagnostic groups showed comparable significant improvement (d = 0.44-0.64). According to level of anxiety, the SFD sample had significantly lower pretreatment scores than did the ANX and the HYP samples. The results suggest that patients with HYP have an interim position between SFD and ANX, with slightly closer connections to ANX.

The effects of safety behaviors on health anxiety: an experimental investigation

The present study examined the extent to which safety behaviors exacerbate symptoms of hypochondriasis (severe health anxiety). Participants were randomized into a safety behavior (n=30) or control condition (n=30). After a baseline period, participants in the safety behavior condition spent one week actively engaging in a clinically representative array of health-related safety behaviors on a daily basis, followed by a second week-long baseline period. Participants in the control condition monitored their normal use of safety behaviors. Compared to control participants, those in the safety behavior condition reported significantly greater increases in health anxiety, hypochondriacal beliefs, contamination fear, and avoidant responses to health-related behavioral tasks after the safety behavior manipulation. In contrast, general anxiety symptoms did not significantly differ between the two groups as a function of the manipulation. Mediational analyses were consistent with the hypothesis that changes in the frequency of health-related thoughts mediated the effects of the experimental manipulation on health anxiety. These findings suggest that safety behaviors are associated with increases in health anxiety, perhaps by fostering catastrophic thoughts about health. The implications of these findings for the conceptualization of hypochondriasis as an anxiety disorder are discussed.

Anxiety as a context for understanding associations between hypochondriasis, obsessive-compulsive, and panic attack symptoms

In the context of the integrative model of anxiety and depression, we examined whether the essential problem of hypochondriasis is one of anxiety. When analyzed, data from a large nonclinical sample corresponded to the integrative model's characterization of anxiety as composed of both broad, shared and specific, unique symptom factors. The unique hypochondriasis, obsessive-compulsive, and panic attack symptom factors all had correlational patterns expected of anxiety with the shared, broad factors of negative emotionality and positive emotionality. A confirmatory factor analysis showed a higher-order, bifactor model was the best fit to our data; the shared and the unique hypochondriasis and anxiety symptom factors both contributed substantial variance. This study provides refinements to an empirically based taxonomy and clarifies what hypochondriasis is and, importantly, what it is not.

A taxometric study of hypochondriasis symptoms

Hypochondriasis has been conceptualized as both a distinct category that is characterized by a disabling illness preoccupation and as a continuum of health concerns. Empirical support for one of these theoretical models will clarify inconsistent assessment approaches and study designs that have impeded theory and research. To facilitate progress, taxometric analyses were conducted to determine whether hypochondriasis is best understood as a discrete category, consistent with the DSM, or as a dimensional entity, consistent with prevailing opinion and most self-report measures. Data from a large undergraduate sample that completed 3 hypochondriasis symptom measures were factor analyzed. The 4 factor analytically derived symptom indicators were then used in these taxometric analyses. Consistent with our hypotheses and existing theory, results supported a dimensional structure for hypochondriasis. Implications for the conceptualization of hypochondriasis and directions for future study are discussed.

Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles

Increased understanding of the nature and role of intrusive imagery has contributed to the development of effective treatment protocols for some anxiety disorders. However, intrusive imagery in severe health anxiety (hypochondriasis) has been comparatively neglected. Hence, the current study investigates the prevalence, nature and content of intrusive imagery in 55 patients who met DSM-IV-TR (APA, 2000) criteria for the diagnosis of hypochondriasis. A semi-structured interview was used to assess the prevalence, nature and possible role of intrusive imagery in this disorder. Over 78% of participants reported experiencing recurrent, distressing intrusive images, the majority (72%) of which either were a memory of an earlier event or were strongly associated with a memory. The images tended to be future orientated, and were reliably categorised into four themes: i) being told ‘the bad news’ that you have a serious/life threatening-illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%). Participants reported responding to experiencing intrusive images by engaging in avoidance, checking, reassurance seeking, distraction and rumination. Potential treatment implications and links to maintenance cycles are considered.

The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.

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.

Is hypochondriasis an anxiety disorder?

Although hypochondriasis is currently classified as a somatoform disorder, the underlying cognitive processes may be more consistent with an anxiety disorder. This observation has important implications for treatment and subsequent revisions of the diagnostic classification of hypochondriasis.

[Hypochondriasis between health and psychosis]

Considering the lack of clarity in the conceptualisation of hypochondriasis, it is not surprising that the concept is quite heterogeneous and that there are dilemmas in terms of what is encompassed by hypochondriasis and where its boundaries are. Therefore, the aim of this review paper was to contribute towards a more coherent view on hypochondriasis, which would also allow its more adequate classification. The essential features of hypochondriasis were identified as an overvalued idea about the presence of disease, fear that the person has already become seriously ill, reassurance-seeking and other forms of health checking, and disturbances in the perception of bodily sensations and symptoms. These four aspects of hypochondriasis can be assessed dimensionally to ascertain to what extent they characterise each patient. Suggestions have been made to delineate more precisely hypochondriasis from health anxiety, anxiety disorders, obsessive-compulsive disorder, other somatoform disorders, personality disorders, depression, and delusional disorder with disease-related delusions. In the absence of better alternatives, hypochondriasis should continue to be classified among the somatoform disorders. In order to improve communication between clinicians and reduce conceptual heterogeneity, the term "hypochondriasis" should be used to refer only to primary hypochondriasis. The pressure to abandon this term should be resisted until an adequate substitution for it has been found.

Psychotherapies for hypochondriasis

BACKGROUND

Hypochondriasis is associated with significant medical morbidity and high health resource use. Recent studies have examined the treatment of hypochondriasis using various forms of psychotherapy.

OBJECTIVES

To examine the effectiveness and comparative effectiveness of any form of psychotherapy for the treatment of hypochondriasis.

SEARCH STRATEGY

1. CCDANCTR-Studies and CCDANCTR-References were searched on 7/8/2007, CENTRAL, Medline, PsycINFO, EMBASE, Cinahl, ISI Web of Knowledge, AMED and WorldCat Dissertations; Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register and clinicaltrials.gov; 2. Communication with authors of relevant studies and other clinicians in the field; 3. Handsearching reference lists of included studies and relevant review articles, and electronic citation search in ISI Web of Knowledge for all included studies.

SELECTION CRITERIA

All randomised controlled studies, both published and unpublished, in any language, in which adults with hypochondriasis were treated with a psychological intervention.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors using a standardised extraction sheet. Study quality was assessed independently by the two authors qualitatively and using a standardised scale. Meta-analyses were performed using RevMan software. Standardised or weighted mean differences were used to pool data for continuous outcomes and odds ratios were used to pool data for dichotomous outcomes, together with 95% confidence intervals.

MAIN RESULTS

Six studies were included, with a total of 440 participants. The interventions examined were cognitive therapy (CT), behavioural therapy (BT), cognitive behavioural therapy (CBT), behavioural stress management (BSM) and psychoeducation. All forms of psychotherapy except psychoeducation showed a significant improvement in hypochondriacal symptoms compared to waiting list control (SMD (random) [95% CI] = -0.86 [-1.25 to -0.46]). For some therapies, significant improvements were found in the secondary outcomes of general functioning (CBT), resource use (psychoeducation), anxiety (CT, BSM), depression (CT, BSM) and physical symptoms (CBT). These secondary outcome findings were based on smaller numbers of participants and there was significant heterogeneity between studies.

AUTHORS' CONCLUSIONS

Cognitive therapy, behavioural therapy, cognitive behavioural therapy and behavioural stress management are effective in reducing symptoms of hypochondriasis. However, studies included in the review used small numbers of participants and do not allow estimation of effect size, comparison between different types of psychotherapy or whether people are "cured". Most long-term outcome data were uncontrolled. Further studies should make use of validated rating scales, assess treatment acceptability and effect on resource use, and determine the active ingredients and nonspecific factors that are important in psychotherapy for hypochondriasis.

Cognitive and perceptual variables in hypochondriasis and health anxiety: A systematic review

This review examined (a) whether hypochondriacal/health-anxious individuals hold distinct assumptions about health and illness, (b) if triggering these assumptions leads to increased hypochondriacal concerns, and (c) whether these individuals perceive their bodily sensations differently from others (i.e., experience greater somatosensory amplification). There was clear evidence that health anxiety is related dysfunctional health-related beliefs. Few studies have examined how hypochondriacal concerns are triggered, and inconsistent results emerged from those that have. Health anxiety is also associated with self-reported higher levels of somatosensory amplification. However, there was little evidence that individuals high in health anxiety are actually more accurate perceivers of the their own autonomic processes. Although the results generally supported the central tenets of the cognitive-behavioral model of hypochondriasis and health anxiety, further research will be necessary to determine whether these beliefs are specific to hypochondriasis and to identify any cognitive processes that may be unique to hypochondriasis.

Generalised anxiety disorder

Generalised anxiety disorder is a persistent and common disorder, in which the patient has unfocused worry and anxiety that is not connected to recent stressful events, although it can be aggravated by certain situations. This disorder is twice as common in women than it is in men. Generalised anxiety disorder is characterised by feelings of threat, restlessness, irritability, sleep disturbance, and tension, and symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognised as part of the anxiety syndrome rather than independent complaints. The symptoms overlap greatly with those of other common mental disorders and we could regard the disorder as part of a spectrum of mood and related disorders rather than an independent disorder. Generalised anxiety disorder has a relapsing course, and intervention rarely results in complete resolution of symptoms, but in the short term and medium term, effective treatments include psychological therapies, such as cognitive behavioural therapy; self-help approaches based on cognitive behavioural therapy principles; and pharmacological treatments, mainly selective serotonin reuptake inhibitors.

Distinguishing between hypochondriasis and somatization disorder: a review of the existing literature

A valid classification is important for further understanding of the somatoform disorders. The main disorders in this grouping - somatization disorder and hypochondriasis - have lengthy historical traditions and are defined in a contrasting manner. Various authors point to distinguishing demographic and clinical features, but there have been few direct comparisons of patients with these disorders. A review of the literature indicates those domains where differences are most likely to be found. Research assessing these may serve to refine and validate these key somatoform categories and/or dimensions.

Somatoform Disorders and DSM-V: Conceptual and Political Issues in the Debate

This article furthers the debate on the future of somatoform disorders by critically reviewing the relevant terminology and validity for the separate grouping and classification of these disorders. It is suggested that political pressures to change certain terms should be resisted, and that such changes should be made only if the alternatives have clear advantages.

Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders

Half of all outpatient encounters are precipitated by physical complaints, of which one third to one half are medically unexplained symptoms, and 20% to 25% are chronic or recurrent. Many of the patients suffer from one or more discrete symptoms, whereas others have functional somatic syndromes. Individual symptoms and somatic syndromes are associated with impaired quality of life, increased health care use, and diminished patient and provider satisfaction. This article provides an overview of (1) unexplained symptoms and somatization; (2) limitations of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in classifying somatoform disorders; (3) predictors of psychiatric comorbidity in patients who have physical symptoms; and (4) measurement and management of symptoms.

The outcomes among patients presenting in primary care with a physical symptom at 5 years

BACKGROUND

Symptoms are common and often remain medically unexplained.

OBJECTIVE

To assess 5-year symptom outcomes, determine how often symptoms remain unexplained and assess their relationship with mental disorders.

DESIGN

Prospective cohort study.

PARTICIPANTS

Five hundred consecutive patients presenting to a medicine clinic with physical symptoms. MEASUREMENTS PREVISIT: Mental disorders, symptom characteristics, stress, expectations, illness worry, and functional status. Postvisit (immediately, 2 weeks, 3 months, 5 years): unmet expectations, satisfaction, symptom outcome, functional status, and stress.

RESULTS

While most subjects (81%) experienced symptom improvement by 5 years, resolution rates were lower (56%), with 35% of symptoms remained medically unexplained. Most patients with medically unexplained symptoms (MUS) did not have a mental disorder. Mood or anxiety disorders were not associated with MUS (relative risks [RR]: 0.94, 95% confidence interval [CI]: 0.79 to 1.13), or with lower rates of symptom improvement (RR: 1.14, 95% CI: 0.60 to 2.2). In contrast, most patients with somatoform disorders had MUS and were unlikely to improve. Worse functioning (RR: 0.95, 95% CI: 0.91 to 0.99), longer duration of symptom at presentation (RR: 0.5, 95% CI: 0.28 to 0.87), illness worry at presentation (RR: 0.56, 95% CI: 0.35 to 0.89), or lack of resolution by 3 months (RR: 0.47, 95% CI: 0.26 to 0.86) reduced the likelihood of symptom improvement at 5 years.

CONCLUSIONS

More than half of patients presenting with a physical symptom resolve by 5 years, while a third remain medically unexplained. Most patients whose symptom remained unexplained had no mental disorder. While mood and anxiety disorders were not associated with MUS or worse outcomes, most patients with somatoform disorders had MUS and were unlikely to improve.

Anxiety in patients with epilepsy: systematic review and suggestions for clinical management

Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.

Assessment of the Hypochondriasis Domain: The Multidimensional Inventory of Hypochondriacal Traits (MIHT)

Although hypochondriasis is associated with the costly use of unnecessary medical resources, this mental health problem remains largely neglected. A lack of clear conceptual models and valid measures has impeded accurate assessment and hindered progress. The Multidimensional Inventory of Hypochondriacal Traits (MIHT) addresses these deficiencies with scales that correspond to a 4-factor model. The MIHT was built with construct validity as a guiding principle and began with an item pool that broadly assessed dimensions identified in the literature. The items were administered to large samples; factor analyses of the responses led to item pool revisions and scale refinements. Multiple studies validated the final MIHT scales and 4-factor model; these findings suggest that the MIHT will contribute to theory and research.