Anxiety, depression, and somatization in DSM-III hypochondriasis

Kellner's Symptom Questionnaire, a Highly Sensitive Patient-Reported Outcome Measure: Systematic Review of Clinimetric Properties

INTRODUCTION

Patient-reported outcomes (PROs) are of increasing importance in clinical medicine. However, their evaluation by classic psychometric methods carries considerable limitations. The clinimetric approach provides a viable framework for their assessment.

OBJECTIVE

The aim of this paper was to provide a systematic review of clinimetric properties of the Symptom Questionnaire (SQ), a simple, self-rated instrument for the assessment of psychological symptoms (depression, anxiety, hostility, and somatization) and well-being (contentment, relaxation, friendliness, and physical well-being).

METHODS

The PRISMA guidelines were used. Electronic databases were searched from inception up to March 2019. Only original research articles, published in English, reporting data about the clinimetric properties of the SQ, were included.

RESULTS

A total of 284 studies was selected. The SQ has been used in populations of adults, adolescents, and older individuals. The scale significantly discriminated between subgroups of subjects in both clinical and nonclinical settings, and differentiated medical and psychiatric patients from healthy controls. In longitudinal studies and in controlled pharmacological and psychotherapy trials, it was highly sensitive to symptoms and well-being changes and discriminated between the effects of psychotropic drugs and placebo.

CONCLUSIONS

The SQ is a highly sensitive clinimetric index. It may yield clinical information that similar scales would fail to provide and has a unique position among the PROs that are available. Its use in clinical trials is strongly recommended.

Somatosensory amplification, health anxiety, and alexithymia in generalized anxiety disorder

AIM

The aim of this study was to study somatosensory amplification, health anxiety (hypochondriasis), and alexithymia among patients with generalized anxiety disorder (GAD) and to evaluate the association of these variables with the severity of GAD.

MATERIALS AND METHODS

Cross-sectional design was employed, and patients were recruited from the outpatient clinic of the psychiatry department of a multispecialty tertiary care medical institute in North India. The patients who were clinically diagnosed to have GAD by the two independent qualified psychiatrists were screened with Mini International Neuropsychiatry Interview to confirm the diagnosis. Forty patients with GAD meeting the inclusion criteria were assessed with GAD-7 scale, somatosensory amplification scale (SSAS), the Whiteley Index (WI) and Toronto alexithymia scale - 20 Hindi version (TAS-H-20).

RESULTS

The mean scores of patients with GAD on SSAS, WI, TAS-H-20, and GAD-7 scale were 25.70 (SD-5.84), 7.75 (SD-3.30), 59.77 (SD- 8.63), and 13.37 (SD- 3.58), respectively. Half of the patients with GAD had significant health anxiety as defined by WI score of >7. Around 40% of GAD patients were alexithymic as defined with TAS-H-20 scores of >60. SSAS, WI, TAS-H-20 had a positive correlation with the severity of GAD as measured with GAD-7 scale.

CONCLUSIONS

GAD patients have significant somatosensory amplification, health anxiety (hypochondriasis), and alexithymia. Accordingly, there is a need to develop effective psychological interventions focused on these factors in GAD.

The Illness Attitude Scales: Adaptation and Translation Into Spanish for Use With Older Adults

The Illness Attitude Scales (IAS) were simplified from a 5-point Likert-type scale to a yes-or-no format and translated into Spanish using Brislin’s method. Because of the linkage between hypochondriasis and depression, the new version was administered to immigrant, Hispanic, older adults suffering from major depressive disorder (MDD) (n= 21) and their controls (n = 21), and to non-Hispanic older adults with MDD (n = 32) and their controls (n = 32). Both versions of the IAS were equivalent and had adequate internal consistency. As hypothesized, Hispanic immigrants with MDD endorsed more hypochondriacal beliefs and were more concerned about the effect of their symptoms than controls. Non-Hispanics were more concerned about pain than controls. The two IAS simplified versions will be useful in the assessment of English- and Spanish-speaking older adults in both clinical and research settings.

Cognitive Behavioural Therapy for Medically Unexplained Physical Symptoms: A Pilot Study

The aim of the study was to develop a cognitive behavioural treatment model for medically unexplained physical symptoms and assess its feasibility and effect in a small sample of patients. This study was the first step in the realization of a randomized controlled trial. The study population consisted of consecutive patients presenting at a general medical outpatient clinic, whose symptoms could not be explained by objective abnormal findings. The treatment was based on a general model of the disorder, consisting of the physical symptoms, the patient's attribution and perceived control and the cognitive, behavioural, physical and social consequences. It incorporated record keeping concerning physical symptoms and emotions, identification of cognitions about the symptoms, challenging dysfunctional thoughts and behavioural experiments. At 6–months follow-up, four of the five treated patients were improved with regard to frequency and intensity of the symptoms, psychological distress and functional impairment. The improvement was sustained at 1–year follow-up.

Hypochondriacal concerns in panic disorder and major depressive disorder: a comparison

OBJECTIVE

To gain perspective on the relationship between hypochondriasis and panic disorder, we compared the occurrence of hypochondriasis in patients with panic disorder (N= 59) and major depressive disorder (N= 27).

METHODS

Patients who participated in separate drug treatment trials were assessed at baseline and eight weeks using the Whiteley Index of Hypochondriasis.

RESULTS

At baseline, the Whiteley Index score was greater for patients with panic disorder than for those with major depressive disorder. At eight weeks, a statistically significant reduction in the mean hypochondriasis score was observed in panic patients who had improved but not in major depressive patients who had improved. Modest correlations were observed between hypochondriasis and symptoms of panic and major depressive disorder, but in depressed patients, hypochondriasis was positively correlated with anxiety symptoms as well.

CONCLUSION

A unique relationship appears to exist between hypochondriasis and panic disorder. The nature of this relationship and its implications for classification are discussed.

Predictors of somatic symptoms in depressive disorder

We explored the relative contribution of potential psychological predictors of somatic symptoms in outpatients with major depressive disorder, including; 1) severity of depression; 2) general anxiety; 3) hypochondriacal worry; 4) somatosensory amplification; and, 5) alexithymia by sampling 100 consecutive outpatients with DSM-IV diagnoses of major depressive disorder attending the psychiatry clinics of general hospitals in Turkey. The subjects were rated by clinicians on depressive symptomatology (Hamilton Depression Rating Scale), and anxiety (Hamilton Anxiety Scale), and completed self-report measures of Hypochondriacal worry (7-item version of the Whiteley Index), the Somatosensory Amplification Scale, and the Toronto Alexithymia Scale. Multivariate models tested the independent contribution of each of the scales to the level of somatic symptoms as measured by a modified version of the SCL-90 somatization scale. At the bivariate level, somatic symptoms were associated with female gender and lower educational level, as well as the Hamilton Depression and Anxiety scales, the Whitely Index, and the Somatosensory Amplification and Alexithymia scales. In multiple regression models incorporating all variables, female gender and higher scores on the anxiety, somatosensory amplification and alexithymia scales all made independent contributions to the level of somatic symptoms and accounted for 54% of the variance. Therefore, somatic symptoms in depression are related to concomitant anxiety, tendency to amplify somatic distress, and difficulty identifying and communicating emotional distress. However, these factors do not account for the tendency for women to report more somatic symptoms.

Anxiety sensitivity, anxiety, and depression in older patients and their relation to hypochondriacal concerns and medical illnesses

This study examined the role of anxiety sensitivity (the fear of anxiety symptoms because such symptoms are believed to have harmful consequences), anxiety, and depression in older adults and their relation to hypochondriacal concerns and medical illnesses. The sample included 53 clinic-referred (M age = 78.8 years), and 53 non-clinic referred (M age = 70.9 years) older adults. It was examined whether (1) anxiety sensitivity was elevated in the clinic-referred group relative to the non-referred group, (2) symptoms of anxiety, anxiety sensitivity and depression were related to number of medical illnesses and/or to hypochondriacal concerns, and (3) anxiety sensitivity was a better predictor of hypochondriacal concerns relative to depression or trait anxiety. The results indicated that anxiety sensitivity was significantly elevated in the clinic-referred group relative to the non-clinic referred group, was negatively associated with history of medical illnesses, was strongly associated with hypochondriacal concerns, and was a better predictor of hypochondriacal concerns than depression and trait anxiety. The findings are discussed in terms of problems facing older adults as they relate to the constructs of anxiety sensitivity and hypochondriacal concerns.

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.

The cognitive-behavioral model of hypochondriasis: misinformation and triggers

According to the cognitive-behavioral model, hypochondriacal individuals hold dysfunctional assumptions about illness, which may be triggered by critical incidents. In this study 1,158 participants completed measures of hypochondriacal concerns and self-esteem, and estimated the likelihood of various symptoms indicating catastrophic and minor illnesses. Participants who were more hypochondriacal believed that catastrophic outcomes were more likely than did the less hypochondriacal participants, but they did not differ in their estimates for minor illnesses. Estimates of the likelihood of catastrophic illness and self-esteem independently contributed to the prediction of hypochondriacal concerns. In this study 2,177 participants completed a measure of hypochondriacal concerns, performed a scrambled-sentences task that included either illness terms or neutral terms, and completed a state anxiety inventory. The illness terms did not trigger higher levels of anxiety in the more hypochondriacal participants; instead, these terms appeared to make the less hypochondriacal participants as anxious as their hypochondriacal counterparts.

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.

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 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.

Physical and mental problems attributed to dental amalgam fillings: a descriptive study of 99 self-referred patients compared with 272 controls

OBJECTIVE

The physical and mental symptomatology of 99 self-referred patients complaining of multiple somatic and mental symptoms attributed to dental amalgam fillings were compared with patients with known chronic medical disorders seen in alternative (N = 93) and ordinary (N = 99) medical family practices and patients with dental amalgam fillings (N = 80) seen in an ordinary dental practice.

METHOD

The assessments included written self-reports, a 131-item somatic symptom checklist; Eysenck Personality Questionnaire, the General Health Questionnaire, and Toronto Alexithymia Scale.

RESULTS

The dental amalgam sample reported significantly more physical symptoms from all body regions. Self-reports suggested that 62% suffered from a chronic anxiety disorder (generalized anxiety disorder or panic). Forty-seven percent suffered from a major depression compared with 14% in the two clinical-comparison samples and none in the dental control sample. Symptoms suggesting somatization disorder were found in 29% of the dental amalgam sample compared with only one subject in the 272 comparison subjects. One third of the dental amalgam patients reported symptoms of chronic fatigue syndrome compared with none in the dental control sample and only 2 and 6%, respectively, in the two clinical comparison samples. The dental amalgam group reported higher mean neuroticism and lower lie scores than the comparison groups.

CONCLUSION

Self-referred patients with health complaints attributed to dental amalgam are a heterogeneous group of patients who suffer multiple symptoms and frequently have mental disorders. There is a striking similarity with the multiple chemical sensitivity syndrome.

Physical symptoms and illness attitudes in adolescents: an epidemiological study

A secondary school population of 805 11-16-year-olds reported lifetime prevalence of 31 physical symptoms and illness attitudes. Girls had a median of six symptoms (range 0-22) and boys five (range 0-22); 67 (8.3%) had 13 or more. Older girls reported more symptoms than younger ones. The excess of symptoms in older girls was related to reporting painful periods rather than simply to age or the menarche. High symptom scorers of both sexes had significantly higher scores on seven Illness Attitude Sub-Scales (Kellner, 1987), with more distress about illness and more treatment experience. The implications of these findings are discussed.

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.

The attribution of somatic symptoms in psychiatric outpatients

The attribution of common somatic symptoms was investigated in 100 psychiatric outpatients. Subjects who were more depressed and alexithymic as measured by the Toronto Alexithymia Scale (TAS) tended to endorse a psychological attribution for somatic complaints. Somatosensory amplification, anxiety, and inability to express and report specific feelings predicted psychological attribution. The data support the role of alexithymia in somatization and further explain a possible role of psychological attribution of somatic symptoms in the underrecognition of physical disorders in psychiatric patients.

Screening for psychiatric symptoms and illness behaviour in a pain clinic

Evolution of a multidisciplinary pain clinic in a rehabilitation hospital is described. The assessment process was facilitated, particularly with respect to psychiatric and psychological evaluation, by the preliminary administration of two well established but simple self-administered questionnaire instruments, the Illness Behaviour Questionnaire (IBQ) and the Crown-Crisp Experiential Index (CCEI). The characteristics of our pain clinic population are described. They demonstrate questionnaire profiles which are typical of pain patients. Attention is drawn to the CCEI profile now shown in three studies of pain patients, predominance of the somatic anxiety (S) scale occurring in all. Correlations between the IBQ and CCEI showed, inter alia, that the S scale is a measure of somatisation in pain patients. This paper aims to describe the changes in the clinic since previously published descriptions, to note the characteristics of our patient on the questionnaire instruments and to comment on the value of these questionnaires in the assessment of psychiatric symptoms and somatisation in pain clinic patients.

Psychiatric disorders in relation to medical illness among patients of a general medical out-patient clinic

In many patients clinical care in general medical settings is complicated by the presence of psychiatric disorders in addition to the presenting physical symptoms. In the present study the prevalence and type of psychiatric disorders was assessed in relation to the medical diagnostic findings in a general internal medicine out-patient clinic. The Present State Examination, a standardized psychiatric interview, was used to detect psychiatric disorders in 191 newly referred patients. Psychiatric disorders were found to be particularly prevalent among patients with medically ill-explained or unexplained symptoms. The prevalence of psychiatric disorders was 15% for patients with a medical explanation for their presenting symptom, 45% for patients with ill-explained and 38% for those with unexplained symptoms. Approximately 40% of the patients with psychiatric disorders met DSM-III-R criteria for somatization disorder or hypochondriasis, suggesting that these disorders contributed in particular to general medical out-patient referrals.

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.

Hypochondriacal concerns and attitudes toward illness in males and females

OBJECTIVE

To review the published studies on the sex distribution of hypochondriasis, and to examine sex differences in hypochondriacal concerns and in attitudes toward illness.

METHOD

The Illness Attitude Scales, Factors 2 and 3 of the Whiteley Index and the Symptom Checklist-90 (SCL-90) were administered to fifty randomly-selected female family practice patients ages eighteen to sixty-five, and to male patients matched by age in decades. From a pool of 130 consecutive nonpsychotic psychiatric outpatients, fifty females and fifty males were matched with the family practice patients.

RESULTS

Although females rated themselves as more depressed than males in both groups, there were no significant differences between the sexes in hypochondriacal fears and beliefs. Psychiatric male patients reported the most adverse effects of bodily symptoms on work and leisure. There were no other significant differences between the sexes in any of the other attitudes toward illness or symptoms. Hypochondriacal concerns were more common in the psychiatric patients than in the family practice patients of both sexes.

CONCLUSION

The review of published studies on the sex distribution of hypochondriasis suggests that disease phobia is more common in females, except for the cardiophobic syndrome, which is more common in males. The other reported differences are inconsistent and appear to be caused by referral biases, varying diagnostic criteria, and cultural factors. In our study, we found no substantial differences between males and females in hypochondriacal concerns and attitudes toward illness.