Psychosomatics 40:387-395, October 1999
© 1999 The Academy of Psychosomatic Medine
Hypochondriasis and Somatization Related to Personality and Attitudes Toward Self
Michael Hollifield, M.D.,
Laura Tuttle, M.D.,
Susan Paine, M.P.H., and
Robert Kellner, M.D., Ph.D.*
Received August 21, 1998; revised October 22, 1998; accepted February 17, 1999. From the Departments of Psychiatry and Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Department of Psychiatry, Duke University, Durham, NC. Address correspondence and reprint requests to Dr. Hollifield, Departments of Psychiatry and Family and Community Medicine, University of New Mexico School of Medicine, 2400 Tucker Avenue, Albuquerque, NM 87131. *Dr. Kellner is deceased.
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ABSTRACT
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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.
Key Words: Hypochondriasis • Somatization • Personality
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INTRODUCTION
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Solomon Katzenelbogen1 reported on hypochondriasis at the 97th Annual Meeting of the American Psychiatric Association and noted that there were few papers in the psychiatric literature on hypochondriasis, perhaps due to the "...fact that hypochondriacal complaints in persons without obvious mental disturbances are seen in general hospitals and dispensaries more frequently than in psychiatric institutions." In his uncontrolled study on symptoms, personality features, and environmental influences in hypochondriasis, Katzenelbogen1 concluded that 1) hypochondriasis is a distinct nosological entity; 2) patients with hypochondriasis usually have numerous complaints involving various systems; 3) the only common characteristic shared by hypochondriacal patients is their unusual and peculiar attitude toward health and sickness rather than distinct personality type; and 4) environmental factors, including iatrogenesis, play a role in the process of hypochondriasis.
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NOSOLOGY
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Since Katzenelbogen, there has been increasing support for the distinct diagnostic entity of hypochondriasis. Pilowsky2 well identified the three dimensions of bodily preoccupation, disease phobia, and disease conviction with nonresponse to reassurance seen in hypochondriasis. While complex relationships exist among anxiety, depression, somatic symptoms, fear of disease, and having a false conviction of having a disease,3 research suggests that hypochondriasis overlaps with—but is probably distinct from—some other psychiatric disorders.4 Barsky et al.5 replicated Pilowsky's earlier work, finding high intercorrelations among disease conviction, disease fear, and bodily preoccupation. Kellner3 has noted that some research supports subdivisions of disease phobia and disease conviction, although this distinction has not made it into nosology. External validity has also been demonstrated in hypochondriasis: subjects have more disability, more distress due to physical symptoms in spite of the same level of physical illness, and higher health care utilization than clinic matched, nonhypochondriacal control subjects.6 Furthermore, hypochondriasis has been found to be stable in a population over a 1-year period.7
However, some studies lead to questions about hypochondriasis as a distinct diagnosis. Discriminative validity for the diagnosis is less sound than internal and external validity.6 Torgerson8 found little evidence for genetic transmission of hypochondriasis in a small family study. Likewise, Noyes et al.9 found no increase in the rate of hypochondriasis among the relatives of hypochondriasis probands, compared with the relatives of control probands. However, somatization disorder was more frequent in the hypochondriasis probands. The diagnostic boundary between somatization disorder and hypochondriasis and the validity of the hypochondriasis diagnosis remain unclear.
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PERSONALITY
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That hypochondriasis is an Axis I disorder has also been questioned. Tyrer et al. argue that hypochondriasis needs to be considered separately in the personality disorder domain.10 Hypochondriacal personality disorder has support from cluster analyses of the Personality Assessment Schedule,11 with hypochondriasis being the most marked feature of the disorder, and with prominent anxiousness, conscientiousness, and dependence.10 Other personality traits that have been associated with hypochondriasis include neuroticism,6–10 narcissism,12–16 avoidance, and histrionic and borderline traits.17 While there are suggestions of abnormal personality development or traits in hypochondriasis,3,17 other studies do not demonstrate characteristic traits,1 or an increase in already established personality disorder from control subjects when assessed with the Structured Clinical Interview for DSM-II (SCID-II).17 A substantial proportion of patients with hypochondriasis do not have an established personality disorder upon clinical assessment.18,19
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THE CURRENT STUDY
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The current study had two primary aims. The first was to characterize dimensions of personality and attitudes toward self exhibited by primary care patients with hypochondriacal beliefs and high somatic concern, using previously validated instruments that are sensitive in detecting hypochondriasis and somatization. The second was to improve knowledge about the relationship between the phenomena of hypochondriasis and somatization by comparing these two groups with a matched primary care control group.
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METHODS
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Design
This study included a cross-sectional, nonprobabilistic sample of patients in a university family practice clinic, to obtain subjects with a spectrum of hypochondriasis, somatization, and neither.
Subjects and Setting
In this study, 302 willing adult subjects were recruited on random, convenient days from the waiting room at the University of New Mexico Family Practice Center over a 4-month period. Seventy-six subjects refused to participate, and 41 subjects turned in study questionnaires too incomplete for analysis (>10% missing in any psychometric scale), so the final sample size was 185 subjects (response rate: 62%).
Instruments
Subjects were recruited by two assistants and were properly administered informed consent and told how to complete the following self-administered questionnaires.
1. Demographic Information.
Demographic information including medical history, health status, information on some health behaviors, and family medical history.
2. Illness Attitudes Scales (IAS).
The IAS contains nine scales comprised of three items each (each item scored 0–4) that measure domains of attitudes, fears, and beliefs about illness, which were previously constructed from 54 nonpsychotic patients who either had disease conviction or displayed hypochondriacal behaviors.20 These scales have been used for studies in various clinical settings, have been found to be highly reliable on test–retest measures, and change in the expected direction with clinical improvement in hypochondriasis. A score of 3 or 4 on any of the six items comprising the hypochondriacal beliefs or disease phobia scales has been shown to identify patients with DSM-III hypochondriasis at a high level of sensitivity.21 In this study, these subjects are designated "hypochondriacal responders" (HR), as a proxy for a spectrum of hypochondriasis. The four scales of thanatophobia, bodily preoccupation, treatment experience, and effect of symptoms were used as dependent measures.
3. Symptom Questionnaire (SQ).
The SQ is a 92-item true–false test with four scales and yields a total score (SQT). The four scales are anxiety (SQA), depression (SQD), hostility (SQH), and somatization (SQS). These scales have a high test–retest reliability, have been validated across various clinical samples, and distinguish community employees from both medical and psychiatric patients.22 An SQS score 14 is "substantial-to-severe" somatization in the absence of physical disease.22 Given the chronic medical disease status in our subjects (described next), an SQS score14 in this study defines "high somatic concern" (HSC) as a proxy for a spectrum of somatization.
4. Attitudes Toward Self (ATS).
The ATS is an 11-item test with a five-point scale for each item with three clusters: positive self-statements, negative self-statements, and a total score.23 A higher total ATS score indicates more negative "attitudes toward self," and is used as a dependent measure.
5. NEO Five-Factor Inventory (NEO).
The NEO is a 60-item test with five-point scoring for each item, comprising five personality domains: neuroticism, extraversion, openness, conscientiousness, and agreeableness. All five domains were used as dependent measures. These domains have been extensively studied and are described in greater detail elsewhere.24
6. Emotional Inhibition Scale (EIS).
The EIS is a 16-item test with a five-point scoring system for each item and yields a single total score measuring a subject's level of expression of his/her emotions and feelings.25 There are also four clusters to the scale: lack of confiding (L), timidity (T), disguise of feeling (D), and self-control (S). The total score "emotional inhibition" is used as a dependent measure.
7. UCLA Loneliness Scale (UCLA).
The UCLA scale is a 20-item test with a four-point scoring system for each item comprising a single scale measuring a general construct of loneliness,26 which is used as a dependent measure. This scale has been validated in a variety of settings across clinical and normative samples.
8. Chronic Disease Score (CDS).
The CDS is a measure of chronic medical illness derived from the patient's use of prescriptions over a 6-month period.27 A score of 0 indicates no medication use for chronic medical illness. A score of greater than 2 is a significant predictor of both hospitalizations and death over a 1-year period, compared with scores of 0 or 1.28 This score has high stability over a 1-year period and has a high correlation with physician ratings of severity of medical illness. The score has also been found to predict hospitalization and mortality in the year following assessment after controlling for age, gender, and health care visits. Medications used for management of symptoms, such as analgesics and anti-inflammatories, and medications used to treat anxiety and depression are not counted in the CDS.
Statistical Analyses
In this study, t-tests and chi-square analyses were performed to determine if there were group differences between the study subjects and refusers for age, educational level, and gender mix. Also, t-tests and chi-square analyses were used to test group differences (HR vs. non-HR and HSC vs. non-HSC) on all demographic variables; medical and family history; the other four IAS scales; the SQ, ATS, NEO, EIS, CDS, and UCLA scales; and health status. We did not use corrections for multiple comparisons because the comparison of each dependent variable to HR and HSC represented a separate hypothesis. An analysis of variance (ANOVA) was performed by using HR status, HSC status, and an interaction between the two to determine the unique and interactive contributions of HR and HSC to the dependent variables.
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RESULTS
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The study sample has been described in a prior report.29 Briefly, the study subjects (N=185) were younger and had more years of education than the refusers (N=76), but these groups did not differ in gender mix. Educational status was not determined for 45.9% (n=85) of the study subjects.
Thirty-eight subjects were HR, 61 had HSC, and 25 (14% of total sample) were both HR and HSC. Although the constructs of HR and HSC were correlated (r=0.46, P<0.01), 34.2% (n=13) of the HR subjects did not have HSC and 60.0% (n=36) of the HSC subjects were not HR (Table 1).
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TABLE 1. Hypochondriacal responders (HR) and high somatic complainers (HSC) in the study sample: N (percent of total sample)
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Demographics
HR Subjects.
The HR subjects and non-HR subjects were similar in gender (female=76.3% vs. 76.9%, P<0.95); ethnicity (79.0% Caucasian non-Hispanic vs. 67.4% Caucasian non-Hispanic, P<0.19); mean±SD age (37.9±11.5 vs. 37.2±12.2, P<0.75); mean±SD years of education (13.9±2.0 vs. 14.5±3.2, P<0.30); and marital status (35.1% married vs. 42.5% married, P<0.42).
HSC Subjects.
The HSC subjects and non-HSC subjects were similar in gender (female=80.3% vs. 75.0%, P<0.43); ethnicity (73.8% Caucasian non-Hispanic vs. 68.3% Caucasian non-Hispanic, P<0.45); mean±SD age (38.9±12.0 vs. 36.6±12.0, P<0.23); mean±SD years of education (14.2±2.6 vs. 14.5±3.2, P<0.74); and marital status (32.2% married vs. 45.2% married, P<0.10).
Personality and Attitudes
HR Subjects.
The hypochondriacal subjects were more neurotic and less extroverted than the non-HR control subjects, but the former did not differ from the control subjects in openness, conscientiousness, or agreeableness (Table 2).
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TABLE 2. Personality and attitudes to self in hypochondriacal (HR) and somatizing (HSC) subjects: raw scores (SD)
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Table 2 also shows scores of loneliness (UCLA), EIS, and attitudes toward self (ATS) for the HR subjects and non-HR control subjects. Compared with the control subjects, the HR subjects were not different with respect to loneliness and emotional inhibition, although they did have more negative self-appraisal.
HSC Subjects.
Compared with the non-HSC control subjects, the HSC subjects were more neurotic, less extroverted, less agreeable, and less conscientious, but they did not differ in openness (Table 2).
Table 2 also shows scores of loneliness (UCLA), EIS, and attitudes toward self (ATS) for the HSC subjects and non-HSC control subjects. Compared with the control subjects, the HSC subjects endorsed more loneliness, more emotional inhibition, and more negative self-appraisal.
Psychological Symptoms
HR Subjects.
The HR subjects scored significantly higher on anxiety (mean±SD: 12.0±5.8 vs. 7.5±6.1, P<0.01); depression (mean±SD: 11.2±6.9 vs. 6.4±6.0, P<0.01); somatization (mean±SD: 14.0±5.0 vs. 8.7±5.7, P<0.01); and hostility (mean±SD: 9.8±6.4 vs. 5.9±5.3, P<0.01) scales of the SQ than the non-HR control subjects.
HSC Subjects.
The HSC subjects scored significantly higher on anxiety (mean±SD: 12.9±5.7 vs. 6.2±5.4, P<0.01), depression (mean±SD: 11.8±6.4 vs. 5.2±5.3, P<0.01), and hostility (mean±SD: 10.3±5.9 vs. 4.9±4.7, P<0.01) scales of the SQ than the non-HSC control subjects. The somatization scale was not analyzed because it was used to derive the construct of HSC.
Chronic Diseases
We were able to collect complete 6-month medication records from automated pharmacy data for 73 of the 185 subjects. The results, described next, are from that group of subjects.
HR Subjects.
Sixteen (22%) of the subjects were HR, and 57 (78%) were non-HR, which is similar to the percentages in the overall sample. The HR subjects had a mean±SD CDS of 1.25±1.5 (range: 0–4) and the non-HR subjects had a mean±SD CDS of 1.05±1.7 (range: 0–8), which is a nonsignificant difference (t=0.43, df=71, P=0.67).
HSC Subjects.
Twenty-eight (38%) of the subjects were HSC and 45 (62%) were non-HSC, which is similar to the percentages in the overall sample. HSC subjects had a mean±SD CDS of 1.25±1.4 (range: 0–4), and the non-HSC subjects had a mean±SD CDS of 1.00±1.7 (range: 0–8), which is a nonsignificant difference (t=0.65, df=71, P=0.52).
ANOVA
When HR status, HSC status, and their interaction were analyzed by ANOVA as independent variables to predict the other dependent variables, the variability in prediction was largely explained by the measured HSC. Table 3 shows that the measured somatization explains the significant variance (P<0.01) in the scores for most of the dependent variables, including those measuring personality (neuroticism and conscientiousness); attitudes to self and loneliness; psychological status (e.g., anxiety); bodily preoccupation; and treatment experience (i.e., frequency of seeking care). Unique contributions of HR were seen only in thanatophobia, and of both HR and HSC in effects of symptoms. The interaction of HSC and HR uniquely and inversely predicted extraversion. The significant interaction effect for extraversion was found because the relationship between HSC and extraversion was stronger for the HR subjects (r=-0.54) than the non-HR subjects (r=-0.14).
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TABLE 3. Analysis of variance (ANOVA): unique contribution of hypochondriasis (HR), somatization (HSC), and their interaction (HRxHSC) to the dependent variables
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The patients in a family medicine clinic with high hypochondriacal responses and high somatic concern are more neurotic, less extraverted, and more distressed psychologically and report more negative self-appraisal than the matched control subjects. However, both the HR and HSC subjects did not have more chronic medical disorders than the control subjects. Thus, the IAS and the SQ distinguished the HR and HSC subjects from the control subjects on measures of personality, psychological distress, and self-appraisal, but not on a measure of medical illness. The somatizing—but not hypochondriacal—subjects were less agreeable, less conscientious, lonelier, and had more emotional inhibition than the control subjects. ANOVA demonstrated that the variance in many of the personality and attitudes to self-measures were associated with HSC and not the hypochondriacal construct. In addition, the presence of somatization was a better predictor of treatment seeking and effects of symptoms on behavior than was the presence of hypochondriasis. These data suggest important boundary differences between somatizers and hypochondriacs.
The current study aligns with other important studies about somatoform disorders that demonstrate that these patients are more distressed than control subjects. This study is unique in demonstrating differences between hypochondriasis and somatization spectrum disorders. The authors were somewhat surprised to find that somatization was associated with a more robust effect on dimensions of personality and attitudes to self than was hypochondriasis, which was more strongly associated with thanatophobia. A concurrent report by the authors reports worse perception of health and higher health care utilization in the somatization group than in the hypochondriacal group defined here.28 Barsky and colleagues5 also demonstrated that physical symptoms—but not the three dimensions of hypochondriasis—predict increased health care seeking, although highly hypochondriacal people do have higher utilization. Noyes and colleagues6 found that the four variables of patient-rated utilization of care, physician-rated utilization of care, health worry and concern, and somatosensory amplification best distinguished hypochondriacs from control subjects. The relationship of overwhelming death anxiety with hypochondriasis has been previously noted by many authors.17,21,29–32 Like the current study, the element of concern with somatic symptoms in these two studies distinguished somatoform patients from control subjects. The current work extends the field by also distinguishing between hypochondriasis and somatization on variables of personality, attitudes to self, and thanatophobia.
The study results do need to be viewed with caution. With the exception of the CDS, these data were obtained from self-report measures. However, it was our intent to test if the IAS and the SQ would distinguish HR and HSC subjects from matched control subjects and from each other. They did. It is known that the IAS and the SQ are very sensitive to the diagnoses of hypochondriasis and somatization, respectively. The specificity of the scales is not as well known. Thus, it is clear to the authors that HR and HSC subjects had a spectrum of hypochondriasis and somatization, and the results may not be generalizable to subjects diagnosed with DSM-IV hypochondriasis and somatization disorder, or to other clinical or community samples. Also, the study subjects were slightly different from those who refused to participate in terms of age and years of education.
The implications of these data could be important if they are duplicated and extended, especially with regard to diagnosis and clinical decision making. A mental disorder is defined as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering, death, pain, disability, or an important loss of freedom."33 Current study data support somatization as diagnostically important, hypochondriasis as perhaps less so, and notes a high comorbidity between the two. The current data also allow for revision of a previous model of hypochondriasis by Kellner (Figure 1)3 to include both hypochondriasis and somatization (Figure 2). Compared with somatizers, people with disease phobia and hypochondriacal beliefs have mild bodily preoccupation, and they may not be more anxious or depressed, or demonstrate more abnormal personality traits or attitudinal characteristics, than normal primary care patients. Rather, it is more likely that the phenomenon of somatization—with or without hypochondriacal beliefs—is associated with severe bodily preoccupation, personality and self-appraisal difficulties, mood and anxiety disturbances, and more treatment seeking because of these symptoms. This model notes the overlap between hypochondriasis and somatization but suggests that there are differences between the two groups that need better identification, including the issue of whether hypochondriasis is a valid Axis I diagnosis or a personality style. One difference may be that pure hypochondriacs are "thinkers" and have prominent cognitive symptoms generating their illness, whereas pure somatizers are "feelers" with more somatic amplification.34 Clarifying this boundary will aid in diagnosis and clinical decision making.
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FIGURE 1. Simplified scheme of hypochondriacal reaction and hypochondriacal neurosis
Note: Brief reactions usually include only some of the elements shown in diagram, whereas hypochondriacal neurosis includes mostFrom Kellner R: Functional somatic symptoms and hypochondriasis: a survey of empirical studies. Arch Gen Psychiatry 1985; 42:821–833.
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R. Noyes Jr., D. R. Langbehn, R. L. Happel, L. R. Stout, B. A. Muller, and S. L. Longley
Personality Dysfunction Among Somatizing Patients
Psychosomatics,
August 1, 2001;
42(4):
320 - 329.
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ABSTRACT
INTRODUCTION
