Psychosomatics 43:282-289, August 2002
© 2002 The Academy of Psychosomatic Medicine
Childhood Antecedents of Hypochondriasis
Russell Noyes, Jr., M.D.,
Scott Stuart, M.D.,
Douglas R. Langbehn, M.D., Ph.D.,
Rachel L. Happel, B.S.N.,
Susan L. Longley, B.A., and
Steven J. Yagla, M.A.
Received December 14, 2001; accepted December 28, 2001. From the Departments of Biostatistics and Psychiatry, University of Iowa Colleges of Medicine and Public Health, Iowa City, Iowa. Address correspondence and reprint requests to Dr. Noyes, Psychiatry Research, Medical Education Building, Iowa City, IA 52242; russell-noyes{at}uiowa.edu (e-mail).
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ABSTRACT
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According to the interpersonal model of hypochondriasis, early environmental adversity may give rise to attachment insecurity that finds adult expression in care-seeking behavior. To identify antecedents of this disturbance, we interviewed general medicine patients and obtained from them self-reports of traumatic events, adverse circumstances, and symptoms experienced in childhood. Patients who met DSM-III-R criteria for hypochondriasis more often reported traumatic events and circumstances, including serious illness or injury. Among all patients, the level of hypochondriacal symptoms in adulthood was correlated with poor health, hypochondriacal worry, and separation anxiety in childhood. These findings are consistent with a growing literature that links childhood adversity to adult hypochondriasis; they support the interpersonal model.
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INTRODUCTION
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Hypochondriasis is a preoccupation with fears of having, or the idea that one has, serious disease in the absence of physical findings.1 According to the interpersonal model outlined by Stuart and Noyes,2 patients with this disorder manifest persistent attempts to elicit care from their families and physicians. Such care-seeking behavior may stem from insecure attachment that originated in early relationships with caregivers.3 Lack of parental care or traumatic circumstances may cause a child to view others as inconsistent or unable to meet its attachment needs.4 Experience with illness or injury may heighten the child's fear of separation and reinforce reassurance-seeking illness behavior. The still insecurely attached adult may convey attachment needs indirectly in the form of physical complaints.5 Yet such unwarranted physical complaints may lead others, including physicians, to question their legitimacy and withhold the sought-after care.6,7
Support for this model comes from a few studies of childhood antecedents of hypochondriasis.8 These have involved varied populations, including psychiatric inpatients, but have shown that childhood adversity may contribute to adult hypochondriasis. Early experience of illness and parental attitudes toward illness have been prominently mentioned. Studies by Barsky et al.9 and Furer et al.10 compared subjects who have DSM hypochondriasis with controls and found more reports of physical and sexual abuse among those with hypochondriasis. They also found, as had Bianchi11 in his study of patients with illness phobia, that more hypochondriacal patients had been sickly and missed school on account of illness as children. Mabe et al.12 obtained reports of serious childhood illness from hypochondriacal inpatients, and Bianchi11,13 obtained evidence of more family illness. Several more studies11,13–15 elicited retrospective reports of parental overprotection or encouragement of sick role behavior during childhood.
Additional support for the interpersonal model may be found in the broader literature on somatization.16 In this literature, childhood illness appears to be important in the development of somatizing behavior. For instance, Craig et al.17 elicited reports of serious childhood illness more frequently from somatizing patients than from nonsomatizers. Parental response to illness in a child may also be a factor. Selective attention to physical symptoms, while emotional needs are being ignored, may reinforce symptom reporting that persists into adulthood.14,18,19 In addition, evidence of inadequate parenting has been obtained in studies of patients with somatization disorder.17,20,21
Traumatic experiences in childhood may also contribute to somatization.16,22,23 A number of studies have found reports of childhood sexual and physical abuse more frequent among patients with somatization disorder and chronic pain.24–30 The specific contribution of these experiences, apart from a more generally adverse environment, remains unclear.24 Exposure to abnormal illness behavior in parents, although not traumatic, may be yet another contributor to somatization. Through social modeling, children may adopt responses to pain and illness that they observe in adults. Indeed, studies of somatizing patients have observed high rates of exposure to parental illness and disability,17,20 and children exposed to parents with chronic pain have reported high levels of somatic symptoms.31,32 To what extent this literature applies to hypochondriasis, a specific form of somatization, is not clear.
Our aim was to test this interpersonal model of hypochondriasis. We hypothesized that an adverse early environment would be associated with adult hypochondriasis and that experience of illness in childhood would be an important contributing factor. We also hypothesized that insecure attachment resulting from this early adversity would be associated with adult hypochondriasis. Data concerning attachment insecurity and interpersonal problems in hypochondriacal adults are reported elsewhere.33
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METHODS
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Subjects
Patients attending the General Medicine Clinic of the University of Iowa Hospitals and Clinics took part in this investigation. A total of 1,612 had scheduled appointments on days when screening took place. Of these, 408 failed to appear, 220 were excluded because of age  65 years, and 235 were excluded because of serious mental or physical illness (e.g., chronic schizophrenia, advanced cancer) or other reasons (e.g., they could not speak English). Another 215 refused to participate, and 534 completed the Health Anxiety Questionnaire (HAQ) used for screening.
As patients arrived for their appointments, they were given a brief description of the study and asked to complete the screening instrument. Those outside the age range 18–65 years and those with severe physical or mental illness were excluded, as were those unable to complete the form. Patients who completed the questionnaire were contacted by telephone within 1 week and asked to participate in a brief interview. To increase statistical power, a sampling formula was adopted that called for enrolling all subjects on the ends of the HAQ distribution and a smaller proportion of those in the middle. According to this formula, 170 patients who had been screened were not contacted. Of the remainder, 162 participated in the study, 149 could not be reached within the specified interval, and 53 declined.
Telephone contacts were completed by a research nurse (R.L.H.) with training and experience in psychiatric interviewing. She administered the hypochondriasis module of the Structured Clinical Interview for DSM-IIII-R and the Childhood Traumatic Events Scale. She also asked subjects to complete and return self-report measures that were mailed to them.
Instruments
Hypochondriasis. Screening was accomplished by use of the HAQ.34 This is a 21-item measure developed to identify individuals with high levels of hypochondriacal concern. Responses are obtained on four-point Likert scales (0 = not at all or rarely to 3 = most of the time). The HAQ has short-term test-retest reliability and appears to have appropriate discriminant validity.34 A distribution of scores for an outpatient population was obtained from the authors. In this study, the measure was highly correlated with the Whiteley Index (r = 0.72).
Hypochondriacal symptoms were assessed by means of the Whiteley Index.35,36 This measure consists of 14 items covering hypochondriacal attitudes and concerns. Responses are obtained on five-point linear scales (1 = not at all to 5 = extremely). The items belonging to this scale form a single factor that has shown good internal consistency.37 Test-retest reliability and both discriminant and convergent validity have been demonstrated.38
Somatic symptoms associated with hypochondriasis were assessed with the Somatic Symptom Inventory.39 This measure consists of 26 items that make up the Minnesota Multiphasic Personality Inventory hypochondriasis scale and the Hopkins Symptom Checklist somatization scale. Responses are obtained on five-point scales (1 = not at all to 5 = extremely). Among medical outpatients, scores on this instrument have been correlated (r = 0.52) with those of the Whiteley Index.38,39 In this study, these measures were also strongly correlated (r = 0.65).
Diagnostic criteria for hypochondriasis were assessed by use of a structured interview. This interview was developed by Barsky et al.39 and follows the format of the Structured Clinical Interview for DSM-III-R.40,41 It has good interrater reliability and both convergent and predictive validity.39,42
Childhood experiences. Traumatic events that might have occurred in childhood were assessed with the Childhood Traumatic Event Scale.43,44 This measure asks respondents whether each of six events occurred before age 17 years, and if so, how traumatic it was on a seven-point scale (1 = not at all to 7 = extremely). The events included death of a very close friend or family member, major upheaval between parents (e.g., separation or divorce), traumatic sexual experience, victim of violence, extreme illness or injury, and other major upheaval. The instrument has been shown to be reliable and valid.43,44
Additional information about childhood environment was obtained by use of two inventories developed by the authors. The first consists of 35 items and asks patients which of the listed events or circumstances occurred (yes vs. no) before age 17 years. These involved the child, his or her parents, close family members, and close friends or neighbors. Events included illness, injury, or abuse of the child and illness, injury, or death of others.
A second inventory asks patients to rate the frequency of a series of 28 symptoms, attitudes, and behaviors in themselves and their parents before age 17 years. Items covered poor health, hypochondriacal worry, separation anxiety, parental concern about health (their own and the child's), and poor parental health. These items were rated from 0 = almost never to 4 = very often.
Parental attitudes. Parental attitudes and behaviors were assessed by the Parental Bonding Instrument.45 With this instrument, the subject rates 25 items separately for mother and father as remembered during the first 16 years of life. Each item is rated on a bidirectional scale (very like to very unlike). Subscales yield scores for care versus indifference/rejection and overprotection versus encouragement of independence for each parent. The instrument has shown acceptable reliability and validity.45,46
Childhood symptoms. Separation anxiety was assessed by means of the Separation Anxiety Symptom Inventory.47 This measure consists of 15 statements regarding fears the person might have had early in life (before age 17 years). Responses are obtained on four-point scales of frequency (1 = feeling occurred very often to 4 = never had this feeling). The scale has been shown to have high internal consistency and test-retest reliability as well as validity against other measures of separation anxiety.47
Childhood hypochondriacal symptoms were assessed by six items from the second childhood inventory described above. These items included worried about health, afraid of becoming ill, worried about getting hurt, bothered by thoughts of death, and fear of death. Each is rated on a five-point scale of almost never to very often.
Poor health during childhood was measured by five items from the second inventory described above. These items included frequent health problems, frequent aches and pains, frailty or weakness, missed school on account of illness, and activities restricted for health reasons.
Statistical Analyses
Relationships between hypochondriasis scales and other continuous variables were examined by means of Pearson correlation coefficients. Because age was negatively correlated with hypochondriasis, partial correlations controlling for age were used. Adjustments were also made for oversampling of subjects with low and high HAQ scores so that estimated values would represent the entire clinic population. These adjustments were accomplished by means of weighted linear modeling.48 The observation weights were derived by first obtaining smoothed estimates of the HAQ score distributions for both the observed sample and the entire clinic population.49,50 The weights were then obtained by taking the ratios of these smoothed density estimates at each HAQ score. (A few HAQ scores were not observed in the sample, and corresponding regions of the estimated population density were redistributed over the six nearest scores. A simple triangle function was used to give greatest redistributed weight to the closest scores.)
Similar linear models, with categorical variables treated as predictors, were used to examine relationships between mean hypochondriasis scores and categorized variables. We also used these models to test differences between patients who met DSM-III-R criteria for hypochondriasis and those who did not when the basis of comparison was a continuous measure (e.g., age). Finally, an analogous, weighted version of logistic regression was used to adjust for age and HAQ-based sampling when differences in dichotomous variables between hypochondriacal and nonhypochondriacal patients were examined. Because sex was not related to the diagnosis of hypochondriasis, this variable was not controlled for in these analyses.
Examination of correlations between items making up the second childhood inventory showed that items covering specific areas were consistently and modestly intercorrelated. Consequently, scores for these areas, including hypochondriacal symptoms, poor health during childhood, and parental reward for sick role behavior, were obtained by summing the individual items.
Estimates of correlations between measures of hypochondriasis and continuous variables for the entire population of general medicine patients (n = 534) were made by use of HAQ scores for all patients.
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RESULTS
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One hundred seventeen women (72.2%) and 45 men (27.8%) participated in this study. Mean age of patients was 51.0 ± 12.2 years. Nearly half (47.8%) were married. Equal percentages (35.4%) were employed or unable to work for health reasons. One hundred fifty-five patients were white, five were black, and two were Hispanic. Over half (62.9%) were receiving public funding for their medical care (federal, state, or county). Forty-nine patients met DSM-III-R criteria for hypochondriasis, and 113 did not. Those with hypochondriasis were younger (mean age 47.6 ± 13.0 vs. 52.7 ± 11.6, P = 0.014) but did not differ significantly with respect to sex or other demographic variables. The above figures apply to the 162 interviewed patients and are not weighted to reflect the entire clinic population. We did not obtain self-rated measures from seven patients, and subsequent analyses are based on 155 participants.
Table 1 shows correlations between Parental Bonding Instrument subscales and measures of hypochondriacal and somatic symptoms. Paternal overprotection was positively but weakly correlated with adult hypochondriacal symptoms, and maternal care was negatively correlated with somatic symptoms.
Severity of childhood trauma was positively but weakly correlated with hypochondriacal and somatic symptoms in adulthood. Scores for the Childhood Traumatic Events Scale (total severity of traumatic events) were positively correlated with hypochondriasis (r = 0.15, P = 0.07) and somatic symptoms (r = 0.23, P = 0.006). Also, one or more traumatic events were reported by 77.2% of hypochondriacal versus 52.1% of nonhypochondriacal patients ( 2 = 5.8, df = 1, P = 0.016). As shown in Table 2, two items on the Childhood Traumatic Events Scale were reported much more frequently by hypochondriacal compared with nonhypochondriacal patients. The difference for extreme illness or injury was statistically significant; that for victim of violence was not.
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TABLE 2. Frequency with which childhood traumatic events were reported by patients with and without hypochondriasis
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Some childhood events or circumstances were reported more frequently by hypochondriacal than by nonhypochondriacal patients, and these are shown in Table 3. Selected items from the 35-item instrument are shown in the table. Some reflect adverse childhood environment, whereas others deal with illness or injury involving the child, his or her parents, and close family members or friends. Events or circumstances reported significantly more frequently by hypochondriacal patients included serious illness and injury during childhood, hazardous occupation in a parent and family member, alcohol or drug problems in a parent and a family member, chronic illness in a family member, and serious illness in a close friend.
Childhood symptoms were also positively correlated with adult hypochondriacal and somatic symptoms, as shown in Table 4. These symptom groupings included poor health in childhood and childhood hypochondriacal worry. Likewise, parental overconcern about the child's health was positively correlated with adult hypochondriasis. However, illness in a parent and parental reward for illness behavior were not correlated.
As is shown in Table 5, modest positive correlations between separation anxiety and hypochondriasis and somatic symptoms were also observed when the Separation Anxiety Symptom Inventory was used. Correlations between various subscales of this measure and the Whiteley Index and Somatic Symptom Inventory were of similar magnitude.
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DISCUSSION
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We found some evidence of adverse early environment among patients with hypochondriasis. This included more frequent reports of traumatic events and of substance abuse in the parents and family members of hypochondriacal patients compared with controls. Three studies, including this one, elicited traumatic events before age 17 years using the Childhood Traumatic Events Scale.9,10 Taken together, they show that such events are reported more frequently by patients with hypochondriasis. However, because the studies differed in design and their findings were not consistent, the combined results must be interpreted cautiously. Still, our findings are consistent with the broader somatization literature that have linked childhood neglect and abuse to unexplained symptoms in adults.16,17,22,30, 51–53 We cannot be certain from these data whether hypochondriacal patients were in fact exposed to early adversity or were influenced by current psychopathology to report such exposure or seek treatment.54 Also, when actual exposure is assumed, it is unclear to what extent genetically determined temperament may have evoked negative responses from parents and others.55
This is a preliminary study, and a number of limitations should be noted. Our results may have been influenced by treatment-seeking and/or referral biases and, as such, may not generalize to the community. Beyond that, some patients were unavailable or chose not to participate; their responses might have differed from those who took part. This study relied on two measures of childhood symptoms and environment that have not been tested for reliability and validity. Furthermore, retrospective report of childhood experiences may have been unreliable. Also, some observed correlations may have reflected general distress not specific to measures used in this study; and relationships examined here may have been influenced by other variables, such as anxiety or depressive symptoms, that were not assessed.56
We found childhood experience of illness predictive of hypochondriasis in adulthood. An experience of serious illness or injury may contribute to the overall adversity of the early environment but may also give rise to a sense of physical vulnerability in a child. Over one-third of our hypochondriacal patients reported that extreme illness or injury before age 17 years had been traumatic. Others have also obtained reports of serious illness in childhood from patients with hypochondriasis.9,10,12 Similar reports have also been obtained from somatizing patients. For example, Craig et al.17 found somatizers to be more likely than physically or emotionally ill primary care patients to report childhood illness that required hospitalization, surgery, or prolonged absence from school. Serious illness or death in a close family member or friend may also undermine confidence in a child's physical being. Consistent with this, more of our hypochondriacal subjects reported exposure to chronic illness in a family member, serious illness in a close friend, and a parent or family member engaged in a hazardous occupation (which suggests risk of injury). Here again, our findings are consistent with those from the literature on somatization.52 Studies have found that somatizers were exposed to serious family illness during childhood more often than nonsomatizers.51,57–60
Evidence that such a sense of physical vulnerability exists in children who later develop hypochondriasis comes from studies that have reported more childhood sickness and absence from school on account of illness. Our hypochondriacal subjects reported poor health in childhood, and others have reported similar findings.9–12 To some extent, these reports may reflect more actual physical illness. However, we also observed a strong positive correlation between poor health and hypochondriacal concerns in childhood (r = 0.49, P < 0.0001). Early hypochondriasis can be seen as a direct expression of such a sense of vulnerability. Of course, hypochondriacal adults may be more likely to recall having been concerned about illness as children on the basis of their current state. However, if confirmed, this would support the notion of childhood susceptibility to hypochondriasis. Adults with medically unexplained symptoms have also tended to recall more sickness during childhood.60 This sickness may represent early unexplained symptoms.53
We observed negative correlations between parental caring and hypochondriacal symptoms and positive correlations between overprotection and these same symptoms. However, both sets of correlations were relatively low, and only those with overprotection approached statistical significance. Parental overprotection or solicitude may undermine a child's confidence in his or her physical health or reward him or her for illness behavior. Studies that have examined such parental attitudes have tended to find them, but the relationships reported have been relatively weak and inconsistent.11,14,15 Using the Parental Bonding Instrument, Parker and Lipscombe14 observed paternal but not maternal overprotection among hypochondriacal family practice patients, and Baker and Mersky15 observed greater maternal overprotection among hypochondriacal than nonhypochondriacal psychiatric inpatients. Of course, these findings involve retrospective report and, even if accurate, would not say whether the parental attitude was the cause or result of worry about health in the child. Parental lack of care has been observed in somatizing patients and might be expected to contribute to an adverse early environment.17
Our finding of significant correlations between adult hypochondriasis and separation anxiety in childhood (r = 0.45) supports the interpersonal model. According to this model, insecure parent-child attachment may produce persistent separation anxiety, which renders the child vulnerable to adult psychopathology.61,62 According to a theory formulated by Bowlby,63,64 childhood separation anxiety is an indirect measure of attachment insecurity. We used a standardized measure of separation anxiety, but any such measure is subject to recall bias.47 Our data suggest that the sources of insecure attachment and separation anxiety in our subjects may include the early adverse environment and experience of illness discussed previously. Findings of more frequent fearful attachment among 4-year-olds with cystic fibrosis and congenital heart disease compared with healthy children supports the idea that serious illness may be a factor that contributs to insecure attachment.65
This study adds to a limited literature reporting early adversity in patients with hypochondriasis. Beyond that, it suggests that evidence of early vulnerability, including hypochondriacal symptoms themselves, may be present in children who later develop this disturbance. It also suggests that an experience of serious illness or injury may be specific in producing a sense of physical vulnerability that gives rise to hypochondriacal worry. Serious illness and injury are increasingly recognized as events that contribute to posttraumatic stress disorder in adults, and the consequences of their occurrence in children are deserving of more attention.54 This study also provides support for the interpersonal model of hypochondriasis. According to this model, adult care-seeking behavior has its origins in insecure attachment. The data suggest that childhood insecurity may be associated with the development of hypochondriasis, and they point to factors that may contribute to that insecurity.
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K. Shear, R. Jin, A. M. Ruscio, E. E. Walters, and R. C. Kessler
Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication
Am J Psychiatry,
June 1, 2006;
163(6):
1074 - 1083.
[Abstract]
[Full Text]
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R. Noyes Jr., C. P. Carney, S. L. Hillis, L. E. Jones, and D. R. Langbehn
Prevalence and Correlates of Illness Worry in the General Population
Psychosomatics,
December 1, 2005;
46(6):
529 - 539.
[Abstract]
[Full Text]
[PDF]
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R. Noyes Jr., S. P. Stuart, D. R. Langbehn, R. L. Happel, S. L. Longley, B. A. Muller, and S. J. Yagla
Test of an Interpersonal Model of Hypochondriasis
Psychosom Med,
March 1, 2003;
65(2):
292 - 300.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
