A family study of hypochondriasis

The Development of Illness Anxiety Disorder in a Patient After Partial Thyroidectomy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), characterises illness anxiety disorder (IAD) 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). DSM-5 includes illness anxiety disorder in the category called somatic symptom and related disorders, characterised by prominent somatic concerns, distress, and impaired functioning. More often than in psychiatric settings, individuals with illness anxiety disorder are encountered in primary care and specialist medical settings. Despite negative laboratory results, the benign course of the alleged disease over time, and adequate reassurances from specialists, their conviction of being ill persists. Illness anxiety preoccupations are heterogeneous, and the degree of insight is variable. Their illness-related preoccupation interferes with their relationships with family, friends, and coworkers. They are frequently addicted to internet searches about their feared illness, inferring the worst from the information (or false information) they uncover. Patients with illness anxiety disorder often have comorbid psychopathology, especially anxiety and depressive disorders. Typically, illness anxiety disorder is chronic. Physical symptoms are absent or mild and frequently represent a misinterpretation of normal bodily sensations. This case report presents the case of a patient diagnosed with IAD by a psychiatrist. The patient had been seen by his primary care physician and therapist for three years without any improvement in his symptoms before he was referred to a psychiatrist. After undergoing a partial thyroidectomy in 2018, this patient has been experiencing increasing symptoms of recurrent anxiety/fear consistent with IAD, despite extensive medical examinations that have consistently revealed normal results.

Family background of modern health worries, somatosensory amplification, and health anxiety: A questionnaire study

In the development of somatosensory amplification, health anxiety, and modern health worries, environmental factors seem more important than genetic background. Parental attitudes might represent a major source of learning. In total, 186 adolescents and their parents completed a questionnaire assessing modern health worries, somatosensory amplification, health anxiety, and somatic symptoms. Adolescents’ modern health worries, somatosensory amplification, and health anxiety were positively related to respective parental characteristics in regression analyses even after controlling for sociodemographic variables and somatic symptoms. Parental beliefs may play a role in the development of these characteristics.

Is obsessive-compulsive disorder an anxiety disorder, and what, if any, are spectrum conditions? A family study perspective

BACKGROUND

Experts have proposed removing obsessive-compulsive disorder (OCD) from the anxiety disorders section and grouping it with putatively related conditions in DSM-5. The current study uses co-morbidity and familiality data to inform these issues.

METHOD

Case family data from the OCD Collaborative Genetics Study (382 OCD-affected probands and 974 of their first-degree relatives) were compared with control family data from the Johns Hopkins OCD Family Study (73 non-OCD-affected probands and 233 of their first-degree relatives).

RESULTS

Anxiety disorders (especially agoraphobia and generalized anxiety disorder), cluster C personality disorders (especially obsessive-compulsive and avoidant), tic disorders, somatoform disorders (hypochondriasis and body dysmorphic disorder), grooming disorders (especially trichotillomania and pathological skin picking) and mood disorders (especially unipolar depressive disorders) were more common in case than control probands; however, the prevalences of eating disorders (anorexia and bulimia nervosa), other impulse-control disorders (pathological gambling, pyromania, kleptomania) and substance dependence (alcohol or drug) did not differ between the groups. The same general pattern was evident in relatives of case versus control probands. Results in relatives did not differ markedly when adjusted for demographic variables and proband diagnosis of the same disorder, though the strength of associations was lower when adjusted for OCD in relatives. Nevertheless, several anxiety, depressive and putative OCD-related conditions remained significantly more common in case than control relatives when adjusting for all of these variables simultaneously.

CONCLUSIONS

On the basis of co-morbidity and familiality, OCD appears related both to anxiety disorders and to some conditions currently classified in other sections of DSM-IV.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

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.

Obsessive-compulsive spectrum of disorders: a defensible construct?

OBJECTIVE

To explore critically whether there is a robust basis for the concept of an obsessive-compulsive (OC) spectrum of disorders, and if so, which disorders should be included.

METHOD

Selective literature review concentrating on three proposed members of the OC spectrum, namely body dysmorphic disorder, hypochondriasis and trichotillomania.

RESULTS

Obsessive-compulsive disorder (OCD) itself is a heterogeneous condition or group of conditions, and this needs to be appreciated in any articulation of a 'spectrum' of OC disorders. The basis for 'membership' of the spectrum is inconsistent and varied, with varying level of support for inclusion in the putative spectrum.

CONCLUSION

A more fruitful approach may be to consider behaviours and dimensions in OCD and OC spectrum disorders, and that this should be encompassed in further developments of the OC spectrum model.

Obsessive–compulsive spectrum of disorders: a defensible construct?

OBJECTIVE

To explore critically whether there is a robust basis for the concept of an obsessive-compulsive (OC) spectrum of disorders, and if so, which disorders should be included.

METHOD

Selective literature review concentrating on three proposed members of the OC spectrum, namely body dysmorphic disorder, hypochondriasis and trichotillomania.

RESULTS

Obsessive-compulsive disorder (OCD) itself is a heterogeneous condition or group of conditions, and this needs to be appreciated in any articulation of a 'spectrum' of OC disorders. The basis for 'membership' of the spectrum is inconsistent and varied, with varying level of support for inclusion in the putative spectrum.

CONCLUSION

A more fruitful approach may be to consider behaviours and dimensions in OCD and OC spectrum disorders, and that this should be encompassed in further developments of the OC spectrum model.

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.

Relationship between hypochondriacal concerns and personality dimensions and traits in a military population

Our aim was to examine the relationship between personality dimensions and hypochondriacal concerns and somatic symptoms in a military population. The Schedule of Nonadaptive and Adaptive Personality along with measures of hypochondriacal concerns and somatic symptoms were administered to 602 military veterans who had been on active duty during the 1991 Gulf War. Factor analyses identified six separable dimensions-two of hypochondriacal concerns, two of somatic symptoms, and two of possible mechanisms of symptom generation-for study. Multiple regression models determined the proportion of variation in these measures of somatic distress explained by personality scales. Personality measures explained between 26% and 38% of the variance in hypochondriacal concerns and somatic symptoms, and Negative Temperament accounted for most of this. Moderately strong positive correlations were observed between trait scales Mistrust, Low Self-Esteem, and Eccentric Perceptions and the various measures of somatic distress. Thus, when Negative Temperament was taken into account, few significant correlations between personality measures and hypochondriacal concerns or somatic symptoms remained. Negative temperament or neuroticism is strongly associated with hypochondriacal concerns. Important features of hypochondriasis and somatic distress appear to lie within the domain of personality. It remains for future research to show whether negative temperament is a vulnerability factor for hypochondriasis or hypochondriasis is itself a personality disorder.

Specific phobia of illness: search for a new subtype

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

Pathophysiology of obsessive–compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by repetitive intrusive thoughts and compulsive time-consuming behaviors classified into three to five distinct symptom dimensions including: (1) aggressive/somatic obsessions with checking compulsions; (2) contamination concerns with washing compulsions; (3) symmetry obsessions with counting/ordering compulsions; (4) hoarding obsessions with collecting compulsions; and (5) sexual/religious concerns. Phenomenologically, OCD could be thought of as the irruption of internal signals centered on the erroneous perception that "something is wrong" in a specific situation. This generates severe anxiety, leading to recurrent behaviors aimed at reducing the emotional tension. In this paper, we examine how the abnormalities in brain activity reported in OCD can be interpreted in the light of physiology after consideration of various approaches (phenomenology, neuropsychology, neuroimmunology and neuroimagery) that contribute to proposing the central role of several cortical and subcortical regions, especially the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), the dorsolateral prefrontal cortex (DLPC), the head of the caudate nucleus and the thalamus. The OFC is involved in the significance attributed to the consequences of action, thereby subserving decision-making, whereas the ACC is particularly activated in situations in which there are conflicting options and a high likelihood of making an error. The DLPC plays a critical part in the cognitive processing of relevant information. This cortical information is then integrated by the caudate nucleus, which controls behavioral programs. A dysfunction of these networks at one or several stages will result in the emergence and maintenance of repetitive thoughts and characteristic OCD behavior.

The obsessive-compulsive spectrums

Because of the paucity of research on the OCSDs, it seems premature to cluster these putative disorders together in DSM, to combine delusional and nondelusional variants of OCSDs, or to classify OCSDs dimensionally. Further investigation of the OC spectrums is clearly needed. These constructs are powerful and useful heuristics with potential validity and clinical utility. The putative OC spectrum and its subspectrums have some apparent advantages over current conceptualizations of these disorders. They may prove more consistent with empirical evidence and ultimately may be shown to better reflect these disorders' pathogenesis. Importantly, they also may be more useful and valid guides for clinical practice.

Epidemiology and treatment of hypochondriasis

Although hypochondriasis has been one of the most durable disease concepts in psychopathology, little is known about its epidemiology and treatment. In this article, we review the last three decades of research into these two aspects of hypochondriasis. According to DSM-IV, hypochondriasis is a distressing preoccupation with the fear or thought, based on physical sensations, that one has a serious disease. The prevalence of hypochondriasis in the general population is unknown; however, studies in primary care suggest that the prevalence in this setting is between 0.8 and 4.5%. There are, at present, no conclusive data about specific risk factors for hypochondriasis, although patients with hypochondriasis have higher rates of anxiety, depressive and other somatoform disorders than patients without the disorder. To date, there have been no studies documenting a genetic or familial predisposition for hypochondriasis, or for somatoform disorders in general. Cognitive behavioural therapy has been shown in controlled studies to be efficacious in the treatment of hypochondriasis. Although the evidence is stronger for individual therapy, group cognitive-behavioural therapy may also be useful. Other therapies such as supportive or psychoanalytical psychotherapy may be efficacious for certain patients, but the lack of standardised treatments and controlled studies makes them a less preferable treatment option at present. Little is known about the pharmacological treatment of primary hypochondriasis. The limited number of published studies and the absence of controlled trials make it impossible to be certain of the efficacy of existing medications. On the basis of the available information, however, it appears that the selective serotonin reuptake inhibitors hold promise for the treatment of this disorder. However, more information is needed for their efficacy to be clearly established.

Intellect and somatic health: associations with hypochondriacal concerns, perceived threat and fainting

BACKGROUND

: Compared to the other domains of the Big 5, intellect has been relatively underresearched with regard to somatic health outcomes. It is argued that this, in part, is because specific hypotheses concerning intellect and somatic health have not been formulated. It is argued that intellect is related to both alexithymia and hypnotic ability. As such the High Risk Model of Threat Perception forms one useful theoretical framework for generating hypotheses about intellect and somatic health. On this basis it is hypothesised that intellect should show a U-shaped relationship to hypochondriacal concerns, a positive association with appraisals of threat and loss, and a negative association with levels of self-reported vasovagal syncope (feelings of faintness).

METHODS

Two cross-sectional studies, using student samples (n = 205, 179), examined the relationships between intellect and hypochondriacal concerns as well as intellect and appraisals of threat and loss. A third prospective study, using a sample of blood donors (n = 373), examined the relationship between levels of self-reported vasovagal syncope and intellect.

RESULTS

Compared to the other domains of the Big 5, intellect demonstrated a U-shaped association with hypochondriacal concerns, a positive association with perceived threat and loss and a negative association with fainting. The negative association with fainting remained once incidence of previous fainting, the number of previous blood donations and emotional stability were held as covariates.

CONCLUSIONS

Intellect is associated in a number of important ways with a variety of psychosomatic variables.

Recognizing hypochondriasis in primary care

Between 5% and 9% of primary care patients exhibit hypochondriacal symptoms. Hypochondriasis may be primary or secondary to panic disorder or depression. Despite negative diagnostic findings and clinician reassurance, hypochondriacal patients manifest disease conviction, disease phobia, or both. Primary care providers, in collaboration with mental health care providers, can provide optimal treatment for patients with hypochondriasis. The use of various intervention phases and selective serotonergic reuptake inhibitors provide the most favorable patient outcomes.

Hypochondriasis and its relationship to obsessive-compulsive disorder

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

Hypochondriacal Concerns: Management Through Understanding

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

Correlates of hypochondriasis in a nonclinical population

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

Hypochondriasis and somatization related to personality and attitudes toward self

Better definition of the boundary between hypochondriasis and somatization was determined by measuring attitudes to self and personality dimensions associated with these syndromes. In this study, the primary care patients with hypochondriacal responses (HR) on the Illness Attitudes Scales or high somatic concern (HSC) on the Symptom Questionnaire had more negative attitudes to self and more psychological distress than the matched group of primary care control subjects. The HR subjects were different from the non-HR subjects on two of five personality domains on the NEO Personality Inventory (NEO)-Five-Factor Inventory, and the HSC subjects were different from the non-HSC subjects on four of five NEO domains. Analysis of variance demonstrated that somatization explained most of the variance in attitudes, personality, and psychological distress, but hypochondriasis uniquely contributed only to thanatophobia. The authors discuss the boundary between hypochondriasis and somatization and offer a descriptive model of this relationship.

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.