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Correlates of Hypochondriasis in a Nonclinical Population

Received February 16, 1999; revised April 28, 1999; accepted June 14, 1999. From the Department of Psychiatry, University of Iowa College of Medicine, Iowa City. Address correspondence and reprint requests to Dr. Noyes, Psychiatry Research, Medical Education Bldg., Iowa City, IA 52242.

ABSTRACT

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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.

Key Words: Hypochondriasis • Prevalence • Comorbidity

INTRODUCTION

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Relatively little is known about the epidemiology of hypochondriasis, and to our knowledge, only one community survey of somatoform disorders has been reported. That study was conducted in Florence, Italy, where a 1-year prevalence of 4.5% was found.¹ Two-thirds of the hypochondriacal subjects were women, and the majority had coexisting anxiety or depressive disorders. However, most of the available data on prevalence, risk factors, and related characteristics have come from general medical and psychiatric populations.^2,3 Because persons in these settings are seeking treatment, these individuals may not be representative of the general population —especially psychiatric patients—and may fall at the extreme end on a spectrum of severity. In the course of conducting a family study of hypochondriasis, we obtained information about hypochondriasis and related characteristics from a group of first-degree relatives.⁴ In addition to psychiatric diagnoses, we obtained information about demographic variables, medical history, impairment in functioning, psychiatric comorbidity, psychiatric symptoms, personality traits, and childhood experiences. These data from a nonclinical population provide an opportunity to see whether available findings generalize beyond the medical clinic setting, where most persons with hypochondriasis have been studied.

Hypochondriasis is, according to DSM-IV, a preoccupation with fears of having, or the idea that one has, a serious disease based on misinterpretation of bodily symptoms.⁵ In contrast to somatization disorder, which is characterized by unexplained somatic symptoms, hypochondriasis is distinguished by a set of beliefs and attitudes about illness. In addition to these defining features, general medical patients with hypochondriasis have shown a number of additional characteristics.⁶ Among such patients, high correlations with depressive, anxiety, and somatic symptoms have been found, and high rates of comorbid depressive, anxiety, and other somatoform disorders have been reported.^7,8 In addition, these patients have scored high on neuroticism, have demonstrated an amplifying perceptual style, and have shown a higher rate of personality disorders than nonhypochondriacal patients.^9,10 Such patients have been shown to be high utilizers of medical services but have reported dissatisfaction with the care they have received.¹¹ In addition to impairment in physical and psychological functioning, they have shown substantial interference with work performance and disability.¹² We hypothesized that similar characteristics would be found among hypochondriacal relatives.

METHODS

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Subjects
We undertook a preliminary study, conducted in 1995, to determine whether hypochondriasis is familial, and if so, what family variables might be associated with the disorder.⁴ To accomplish this, we selected hypochondriacal and nonhypochondriacal probands from a general medicine clinic and personally interviewed as many of their first-degree relatives over age 18 as possible. The 169 interviewed relatives became the study's subjects. They represented 56.7% of all first-degree relatives; the remainder refused (23.2%), were not located (2.0%), were deceased (18.1%). The interviewed relatives included 106 women and 63 men, with a mean age of 43.3 (standard deviation [SD]: 15.9).

The relatives were interviewed in their homes (41%) or by telephone (59%) if they lived more than 150 miles from Iowa City. The Structured Clinical Interview for DSM-IV was modified to include the hypochondriasis module developed by Barsky et al.^12,13 This instrument was administered blindly by a research nurse experienced in psychiatric interviewing and trained in use of this instrument. The interviewer also obtained a brief medical history using a structured interview developed for this study. This interview included questions about the number of serious illnesses, serious injuries, hospitalizations, surgical procedures, and extended disability (>1 month). A list from the National Health Interview Survey was used to obtain information about lifetime medical conditions.¹⁴ The relatives were asked a series of questions about childhood experiences. Responses for most of them were rated as 0=absent, 1=slight or doubtful, or 2=definitely present. The items dealt with illness during childhood (poor physical health, serious illness or injury, restriction of activities for health reasons, absence from school on account of illness); negative parental factors (physical illness in a parent, separation from a parent, parental overprotectiveness, parental neglect, physical abuse, sexual abuse); and psychological distress in childhood (behavioral inhibition, childhood anxiety or depression, phobias in childhood).

Questionnaires
Measures of hypochondriasis included the Whiteley Index, Somatic Symptom Inventory, Illness Attitude Scales, and Somatosensory Amplification Scale. The Whiteley Index contains 14 items shown by Pilowsky¹⁵ to discriminate between hypochondriacal and nonhypochondriacal patients.¹⁶ A modification of the instrument by Barsky et al.¹² calls for rating items on five-point scales. The Somatic Symptom Inventory consists of items from the Symptom Checklist-90's somatization scale and the Minnesota Multiphasic Personality Inventory's hypochondriasis scale. The inventory is composed of 26 items rated for the past week on five-point scales ranging from 1=not at all to 5=extremely. This measure has been validated in studies of hypochondriasis, in which strong correlations with the Whiteley Index were shown.^11,12 The Illness Attitude Scales were developed by Kellner^17,18 to measure hypochondriasis, together with associated attitudes and behaviors. The scales are each composed of three items rated on five-point scales. They include worry about illness, concern about pain, health habits, hypochondriacal beliefs, thanatophobia, disease phobia, bodily preoccupation, treatment experience, and effects of symptoms. The scales have adequate test-retest reliability and have been shown to discriminate between patients with and without abnormal illness behavior. The Somatosensory Amplification Scale was used to assess sensitivity to various unpleasant but nonpathological bodily and environmental sensations on five-point ordinal scales.¹⁹ The scale has high internal consistency and good test-retest reliability.¹²

The Brief Symptom Inventory was used to assess severity of somatic and psychological symptoms.²⁰ This is a 53-item version of the widely used and validated Symptom Checklist-90.²¹ Subscales derived by factor analysis include somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. To measure worry, which in hypochondriasis is focused on health, we used the Penn State Worry Questionnaire²² that contains 16 statements rated on five-point linear scales. The measure has shown excellent psychometric properties in student and clinical populations.²³

To assess personality among the relatives, we used the NEO Personality Inventory (NEO-PI) and the Toronto Alexithymia Scale (TAS). The NEO-PI measures five personality dimensions: neuroticism, extraversion, openness, agreeableness, and conscientiousness. The short form, developed by Costa and McCrae,²⁴ consists of 60 items rated on five-point dichotomous scales of agreement. The NEO-PI provides assessment of five basic personality dimensions and has proven valid in normal and clinical samples.²⁵ The TAS was used to measure inability to identify and report feelings and an externally oriented, concrete mode of thinking.^26,27 The revised TAS is a 23-item instrument shown to have internal consistency, good reliability, and both construct and criterion validity.²⁸ Overall impairment in personality functioning was measured by the impairment/distress scale of the Personality Diagnostic Questionnaire (PDQ).^29,30 This subscale, which is made up of five items, correlates highly with the total PDQ. We modified it by substituting five-point ordinal scales for the dichotomous response categories.

To assess level of functioning, health status, and medical care, we used the Functional Status Questionnaire. The Functional Status Questionnaire is a brief, self-report measure of established reliability and validity that was developed for use in ambulatory-care populations.³¹ It contains subscales covering the areas of physical functioning, work performance, psychological functioning, and social functioning. The instrument has been used in studies of hypochondriacal outpatients.^11,12

Diagnoses
Best-estimate diagnoses were assigned by two investigators, according to DSM-IV criteria.⁵ These investigators were blind to proband status and based their independent assessments on all available information. This information included psychiatric history from the proband, records of medical and psychiatric treatment, and the interviewer's detailed narrative. DSM-IV criteria were used, except for the diagnosis of hypochondriasis, for which most exclusionary rules were set aside. As in DSM-III-R, hypochondriacal symptoms were not just symptoms of panic attacks and were not of delusional intensity. A diagnosis of possible hypochondriasis fulfilled the same criteria, except that evidence of impairment was not elicited (Criterion D). Diagnostic disagreement between the investigators was resolved by discussion.

Analysis of Data
Because the prevalence of hypochondriasis did not differ between the families of the hypochondriacal and nonhypochondriacal probands, we combined the relatives from these families for our analyses. Also, because dimensional (Whiteley Index and Somatic Symptom Inventory) and categorical (definite and possible DSM-IV diagnoses) measures of hypochondriasis were used in the family study, we used both in the analyses we undertook. Differences between the hypochondriacal and nonhypochondriacal relatives were examined by means of Student's t-tests (two-tailed) for continuous variables and chi-square or, where appropriate, Fisher's exact tests (two-tailed) for categorical variables. Pearson correlation coefficients were used to examine relationships between continuous variables and measures of hypochondriasis. Where dichotomous variables were concerned, differences between mean scores on the Whiteley Index and Somatic Symptom Inventory were examined by using Student's t-tests (two tailed). Although this study involved a large number of comparisons, we chose not to apply a Bonferroni correction but report P-values of <0.05 for descriptive and comparative purposes.

RESULTS

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Thirteen of the 169 interviewed relatives met definite criteria for hypochondriasis and 5 more met possible criteria. The relatives with hypochondriasis (definite and possible) were older (mean ± SD: 47.4 ± 15.7 years vs. 42.9 ± 15.7 years), but not significantly so. There was a trend toward more women among those with hypochondriasis (83.3% vs. 60.3%, ²=3.7, df=1, P=0.06). The difference in percentage of non-White persons among the hypochondriacal and nonhypochondriacal relatives was not statistically significant (11.1% vs. 5.3%, ²=1.0, df=1, NS). Educational level showed low negative correlations (r=-0.14 and-0.15), and occupational class showed low positive correlations (r=0.20 and 0.20) with the Whiteley Index and Somatic Symptom Inventory.

The hypochondriacal relatives (definite and possible) had more current (mean ± SD: 1.8 ± 1.6 vs. 0.5 ± 0.9, P<0.005) and lifetime (3.1 ± 1.2 vs. 1.2 ± 1.5, P<0.005) psychiatric disorders, compared with the nonhypochondriacal relatives. Also, the more hypochondriacal relatives had current and lifetime anxiety disorders (77.8% vs. 13.3%, ²=41.7, df=1, P<0.001 and 77.8% vs. 20.5%, ²=22.3, df=1, P<0.001); mood disorders (33.3% vs. 9.3%, ²=8.8, df=1, P<0.005 and 55.5% vs. 31.1%, ²=4.3, df=1, P<0.05); and other somatoform disorders (50.0% vs. 11.3%, ²=18.5, df=1, P<0.001 and 50.0% vs. 11.3%, ²=18.5, df=1, P<0.001), but not substance use disorders. With respect to current anxiety disorders, four hypochondriacal relatives had none, six had one, and eight had two or more. Individual disorders included panic disorder (8), posttraumatic stress disorder (5), social phobia (5), specific phobia (5), generalized anxiety disorder (2), and agoraphobia without panic disorder (1).

As shown in Table 1, hypochondriacal relatives had higher levels of psychiatric symptoms, as measured by the Brief Symptom Inventory. Also, positive correlations between the Brief Symptom Inventory subscales and the Whiteley Index and Somatic Symptom Inventory were high. As expected, the hypochondriacal relatives obtained higher scores on the Illness Attitude Scales, which independently measured hypochondriacal concerns (Table 1).

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TABLE 1. Mean ± SD on measures of general psychiatric and hypochondriacal symptoms obtained from hypochondriacal and nonhypochondriacal relatives. Also shown are correlations between various subscales and the Whiteley Index and Somatic Symptom Inventory

The hypochondriacal relatives reported more lifetime medical morbidity and health care utilization, compared with the nonhypochondriacal relatives. As shown in Table 2, the hypochondriacal relatives claimed more lifetime conditions and hospitalizations than did the nonhypochondriacal relatives. For the past 12 months, more hypochondriacal relatives reported physical limitations (66.7% vs. 42.3%, ²=3.8, df=1, P=0.05) and inability to work (61.1% vs. 33.7%, ²=5.2, df=1, P<0.05). Increased health care utilization in the past 12 months took the form of more doctors seen, more doctor visits, and more medications taken. The hypochondriacal relatives rated their health as worse than did the nonhypochondriacal relatives, and these overall ratings showed strong positive correlations with the Whiteley Index and Somatic Symptom Inventory among all relatives. In the past month, they reported more days in bed, more days of having to decrease activities, and less satisfaction with health. In addition, the hypochondriacal relatives showed poorer current functioning in all areas, as indicted by lower scores on the Functional Status Questionnaire, than did the nonhypochondriacal relatives. They also reported having had more functional somatic syndromes (e.g., fibromyalgia, chronic fatigue syndrome: mean ± SD: 3.7 ± 2.0 vs. 1.9 ± 1.3, P<0.02).

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TABLE 2. Mean ± SD values for medical history variables obtained from hypochondriacal and nonhypochondriacal relatives. Also shown are correlations between these variables and the Whiteley Index and Somatic Symtom Inventory for all relatives

With respect to childhood experiences, the hypochondriacal relatives differed little from the nonhypochondriacal relatives. However, as shown in Table 3, a greater proportion reported poor health as a child, and more hypochondriacal relatives claimed to have had childhood phobias. Also, the relatives who experienced anxiety or depressive symptoms, phobias, or serious illness or injury (trend) as a child obtained higher scores on the Whiteley Index and Somatic Symptom Inventory. When childhood factors were combined, the hypochondriacal relatives obtained higher scores for childhood illness (0.7 ± 0.8 vs. 0.3 ± 0.7, P<0.05) and psychological distress (0.8 ± 0.8 vs. 0.4 ± 0.6, P<0.05) than the nonhypochondriacal relatives.

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TABLE 3. Proportion of hypochondriacal and nonhypochondriacal relatives who had various childhood experiences. Also shown are mean ± SD scores on the Whiteley Index and Somatic Symptom Inventory for relatives who reported and did not report these experiences (present vs. absent)

Table 4 shows comparisons between the hypochondriacal and nonhypochondriacal relatives on personality measures. The former obtained higher scores on neuroticism but lower scores on conscientiousness. The hypochondriacal relatives also obtained higher scores on both dimensions of alexithymia, inability to express feelings and externally oriented thinking. In addition, the hypochondriacal relatives scored higher on a brief measure of distress and impairment related to personality dysfunction, the impairment/distress subscale of the Personality Diagnostic Questionnaire. Sixty percent of the hypochondriacal and 36.5% of the nonhypochondriacal relatives scored 9 on this scale (²=3.2, df=1, P=0.08). The hypochondriacal relatives also scored higher on the Somatosensory Amplification Scale (29.9 ± 6.4 vs. 23.5 ± 6.5, P<0.001), and scores on this scale were positively correlated with the Whiteley Index (r=0.50) and Somatic Symptom Inventory (r=0 .53) for all relatives.

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TABLE 4. Mean ± SD scores on personality measures obtained from hypochondriacal and nonhypochondriacal relatives. Also shown are correlations between these measures and scores on the Whiteley Index and Somatic Symptom Inventory for relatives

DISCUSSION

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This study is preliminary and, as such, has a number of limitations. First of all, original probands for the family study were obtained from a much larger pool. Many otherwise eligible patients chose not to participate or could not be contacted. Consequently, selection may have influenced results.⁴ Second, the study involved family members of patients who attended a general medicine clinic at a university hospital. Therefore, the findings may not be generalizable to the general population. Third, comparisons between the hypochondriacal and nonhypochondriacal relatives were based on small numbers, so that existing differences may not have been detected. Fourth, we ran multiple comparisons, thereby increasing the likelihood of obtaining positive findings by chance. Finally, the diagnosis of hypochondriasis presents difficulties and its reliability remains largely untested. The diagnosis requires judgment about the extent to which somatic symptoms are explained by physical disease and the extent to which health worry is excessive.³²

We identified DSM-IV hypochondriasis in 7.7% of the relatives, but with the addition of subsyndromal cases the prevalence rose to 10.7 %. These figures are within the 2.2% to 10.3% range for general medicine patients, but the numbers seem high for a nonclinical population.^2,3 Faravelli et al.¹ reported a 1-year prevalence of 4.5%, but few other estimates for the general populations are available. Still, Argas et al.³³ identified fear of illness in 16.5% of persons in Vermont, and Kellner and Sheffield³⁴ found 9% and 13% of persons in England and New Mexico, respectively, worried that they might have serious disease. Our rates may reflect high levels of psychopathology among the medical patients who served as probands as well as the higher proportion of female relatives who participated in this study. As noted earlier, rates for all disorders were high in the family study, suggesting a tendency to overdiagnose. However, even when we used a lowered threshold for diagnosis, we demonstrated morbidity in our hypochondriacal relatives that was comparable to that observed in our original family study probands. Gureje et al.³⁵ similarly observed that dropping one of the ICD-10 criteria—in this instance failure to respond to reassurance—increased prevalence among primary care patients several-fold without reducing impairment.

Our hypochondriacal relatives were somewhat less severe than the hypochondriacal patients who served as probands for the family study (Whiteley Index: 36.3 ± 14.4. vs. 43.8 ± 5.0, P=0.07 and Somatic Symptom Inventory: 63.9 ± 23.0 vs. 83.5 ± 15.7, P<0.01). However, in other respects this nonclinical population appeared similar to previously reported clinical samples. For instance, our hypochondriacal relatives had a high rate of comorbidity with anxiety, mood, and other somatoform disorders, as Barsky et al.⁷ and Noyes et al.⁸ have observed. Also, we found strong positive correlations with psychiatric symptoms, especially anxiety and depression, as have been observed in clinical samples.^11,36 In addition, we found substantial physical and psychological impairment in functioning, including diminished work performance and disability, that have consistently been reported in general medicine populations.^11,12 In line with this, we also observed greater utilization of health care and less satisfaction with care, often seen in hypochondriacal patients.^37–40

Certain childhood experiences have been previously observed in hypochondriacal patients. For instance, Barsky et al.⁴¹ obtained more frequent histories of both physical and sexual abuse as well as parental upheaval from hypochondriacal general medicine patients than from nonhypochondriacal patients. We did not find this in our small sample, suggesting that these factors might be associated with treatment seeking rather than hypochondriasis itself.⁴² Like Barsky et al.,⁴¹ we found childhood illness more frequent among our hypochondriacal relatives. Such illness might simply reflect early onset of hypochondriasis.⁴³ On the other hand, early experiences of illness may, as many authors have suggested, be important in the development of the disorder.^18,44 Anxious and phobic symptoms also may have been childhood manifestations of hypochondriasis or may have rendered individuals vulnerable to its later development.

In our hypochondriacal relatives, we observed a high level of neuroticism. Also, among all relatives we found a strong positive correlation between neuroticism and measures of hypochondriasis. Neuroticism is a factor associated with symptom reporting and hypochondriasis.^10,45 Whether this personality dimension represents premorbid vulnerability or a consequence of hypochondriasis and/or coexisting disorders is difficult to say. The hypochondriacal relatives also scored higher on at least one of the alexithymic dimensions, indicating that they may have more difficulty identifying and expressing feelings. Recent studies have demonstrated an association between alexithymia and somatic symptoms.⁴⁶ This finding has been interpreted to mean that, because alexithymic individuals are unable to express feelings or link them to accompanying somatic sensations, they are less able to cope with stressful circumstances.^46,47 We also identified a greater tendency toward somatosensory amplification among our hypochondriacal relatives, which has previously been observed among hypochondriacal patients.^6,19

Among our hypochondriacal relatives, we observed an especially close relationship with anxiety. Not only did these relatives have phobic tendencies, including disease phobia and thanatophobia, but they also had high levels of anxiety and phobic symptoms as well. Anxiety and phobic symptoms were also experienced in childhood and again in adulthood when comorbidity with anxiety disorders was especially high. There is evidence from the literature of phenomenological overlap between hypochondriasis and several anxiety disorders, including panic disorder with agoraphobia, specific phobia, generalized anxiety disorder, and obsessive–compulsive disorder.^48–51 There is evidence of anxiety and phobic symptoms among hypochondriacal patients, and hypochondriacal concerns among some patients with anxiety disorders. Beyond that, there appears to be considerable shared comorbidity.^1,7,8 Also, subtypes of hypochondriasis may exist, and a link between one of them, illness phobia, and anxiety disorders has been suggested. Based on his review of the literature, Noyes⁵² concluded that hypochondriasis is distinct from the anxiety disorders but, because of phenomenological similarities and extensive comorbidity, should probably be classified among them.

Our study examines the prevalence, risk factors, and comorbidity of hypochondriasis in a nonclinical population. The findings from such a population are significant because they are not influenced by treatment-seeking bias. This bias is especially important when it comes to hypochondriasis because, by its very definition, the disorder involves treatment-seeking behavior and "persists despite appropriate medical evaluation and reassurance."⁵ Consequently, findings from primary care might be strongly influenced by factors that influence the decision to obtain treatment. However, we found little evidence of this; our findings are similar to those done on general medical populations. Thus, the prevalence of hypochondriasis appears high, indicating that the disorder warrants more attention than it has been receiving. Demographic variables appear relatively unimportant, but certain childhood factors and personality traits may contribute to development of the disorder. The high rates of comorbidity suggest that understanding hypochondriasis will depend upon an appreciation of its interactions with coexisiting disorders. Study of prevalence, risk factors, and comorbidity need to be extended to the general population.³ Recent community surveys have largely ignored the somatoform disorders, so that much remains to be learned about their epidemiology.

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