Hypochondriasis and Illness Phobia in Panic-Agoraphobic Patients

Alessandra Benedetti, Giulio Perugi, Cristina Toni, Beatrice Simonetti, Belen Mata, and Giovanni B. Cassano

In a sample of 131 patients with panic disorder, we anticipatory anxiety in nonagoraphobic situations and explored both the presence of DSM-III-R criteria for more depersonalization and derealization during panic hypochondriasis and the occurrence of illness phobia attacks, and they met our definition of phobic-anxious before the onset of panic disorder. To explore further temperament more frequently than the rest of the the possible relationship between hypochondriacal sample. This would suggest that illness phobia before features and panic-agoraphobic syndrome, we com- the onset of panic disorder may be viewed either as a pared patients both with and without current hypo- separate disorder, a prodrome, or a mild, early-onset chondriasis and then patients both with and without form of panic disorder without full-blown attacks. illness phobia before the onset of panic disorder. Although patients with premorbid illness phobia are Finally, we investigated the relationship between more likely to develop hypochondriasis after the onset premorbid phobic-anxious traits and hypochondriasis of panic disorder, approximately 40% of them do not; during panic disorder. No differences were found therefore, illness phobia should not be considered the between patients with and without hypochondriasis, only factor that influences the development of hypo- either in terms of clinical features or in the course of chondriasis during panic disorder. panic disorder. Patients with illness phobia before the Copyright © 1997 by W.B. Saunders Company onset of panic disorder reported higher levels of

HE TERM HYPOCHONDRIASIS was intro- that the disorder has a relatively independent T duced by Aretaeus of Cappadocia during the status. 8 first century B.C. At that time, it referred to an The relationship between panic disorder, illness accessory symptom of melancholia, but during the phobia, and hypochondriasis has recently been the last century it has come to mean either believing focus of attention of investigators and clinicians. 8-19 that there is a disease when none exists or having an Fear and/or the conviction of being affected by a exaggerated fear of acquiring an illness. somatic disease has been observed in 25% to 60% The DSM-III2 and DSM-IV 3 definition of hypo- of patients with panic disorder or related syn- chondriasis includes only what is probably the most dromes. 1°,13-16,2° The wide variation in reported severe end of a spectrum of various types of fears rates is presumably accounted for by differences in and beliefs. Various observations of undue concern diagnostic and sample-selection procedures. On the about bodily functions that do not fulfill the criteria other hand, Warwick and Salkovskis 12 reported that for the diagnosis of hypochondriasis have sug- 59% of hypochondriacal subjects met the criteria gested several distinctions in this field. 4 According for panic disorder. Therefore, although the nature to Marks, 5 for example, illness phobia constitutes a of the relationship between the two diagnostic focal form of hypochondriasis, focused on a single categories has not been sufficiently investigated, symptom or illness. Patients with illness phobia both disorders would seem to be epidemiologically have a pathological fear of getting a specific and clinically related.15 disease, whereas patients with hypochondriasis are According to DSM-IV criteria, 3 a diagnosis of overwhelmingly afraid that they may already be suffering from one or more diseases. 6 This defini- hypochondriasis should not be made if hypochon- tion overlaps partially with the proposed diagnostic driacal symptoms (such as bodily concerns, fear of criteria for use in psychosomatic research for illness, or conviction of being affected by a somatic disease phobia. 7 In the current classifications) disease) are "better accounted for by Panic Disor- illness phobia is listed within the broad heading of der." For the Manual, a complete hypochondriacal hypochondriasis. However, there is some evidence syndrome, or some aspects of it, that first appears during the course of panic disorder but then disap- pears after successful treatment for panic disorder From the Psychiatric Clinic, University of Pisa, Pisa, Italy. must be considered secondary. However, recent Address reprint requests to Giulio Perugi, M.D., Via Roma studies 9,21-22have reported cases in which hypochon- 67, 56100, Pisa, Italy. Copyright © 1997 by W.B. Saunders Company driacal fears or beliefs are present before the onset 0010-440X/97/3802-0003503. 00/0 and persist after the remission of panic disorder. In

124 Comprehensive Psychiatry, Vol. 38, No. 2 (March/April), 1997: pp 124-131 HYPOCHONDRIASIS IN PANIC-AGORAPHOBIA 125 such patients, panic attacks would appear to be An intensive face-to-face interview that consisted of struc- qualitatively different from those found in panic tured and semistrnctured components was the means of collect- disorder and should be considered secondary phe- ing data. The interview lasted approximately 1 hour at baseline and 30 minutes during subsequent visits. The interviews were nomena of hypochondriasis. Confirming this hy- conducted by residents with experience in the diagnosis and pothesis, it has been reported also that these treatment of anxiety disorders. Each interviewer underwent a patients rarely develop agoraphobia and that suc- training program in the use of the interview instruments that cessful treatment decreases the frequency of panic included direct observation of experienced interviewers, direct attacks but does not relieve hypochondriacal fears. 21 supervision of interviews, and interrater trials. The most experi- enced interviewers provided direct supervision of the other On the contrary, Starcevic et a1.16 found higher rates clinicians. of agoraphobia in patients with both panic disorder Because data collection was largely dependent on patient and hypochondriasis, and they reported that hypo- recall of historical information, the diagnostic determinations in chondriasis improves with adequate treatment for the study had to be considered estimates and therefore subject to panic disorder. Noyes et al. r0 confirmed this obser- inaccuracies. However, to take into account this limitation of retrospective descriptive studies, all data collected were re- vation in a sample of 60 panic patients, reporting viewed by the interviewer team for the purpose of consensual that in a large percentage of patients, most hypo- agreement. When questions arose, patients were reapproached chondriacal fears and beliefs disappeared after a for further clarification. In some cases, patients' medical records 6-week treatment for panic disorder. However, it is were reviewed and information was obtained from family unclear whether these last two studies included members and previous physicians. patients who had suffered from illness phobia or The diagnostic instrument was the Structured Clinical Inter- view for DSM-III-R (SCID-II) by Spitzer and Williams. 24 hypochondriasis before the onset of panic disorder. According to this instrument, 80.1% of the sample suffered from In the present study conducted in a large sample panic disorder with agoraphobia; the remaining patients had of patients with panic disorder, we explored both uncomplicated panic disorder. The mean age at onset was 28.7 the presence of DSM-III-R 23 criteria for hypochon- years (SD, 9.7; range, 9 to 54) for panic disorder and 29.6 years driasis and the occurrence of illness phobia before (SD, 10.3; range, 3 to 55) for agoraphobia; the mean duration of illness was 75.6 months (SD, 92.0; range, 0 to 440), the onset of panic disorder. Furthermore, to explore Demographic and illness characteristics were obtained with the possible relationship between hypochondriacal the Questionario Panico-Agorafobia (QPA). 25 This semistruc- features and panic-agoraphobic syndrome, we com- tured interview permitted the use of the first panic attack as the pared patients both with and without current hypo- primary anchoring point. The majority of patients recalled this chondriasis and then patients both with and without attack with clarity and precision. Once the period of the first panic attack had been described, years preceding and following illness phobia before the onset of panic disorder. this event were reviewed. The instrument is subdivided into Finally, we investigated the relationship between different sections exploring (1) demographic characteristics, premorbid phobic-anxious traits and hypochondria- based on the Adult Personal Inventory Data26; (2) first-degree sis during panic disorder. psychiatric loading according to the Winokur approach as incorporated into the family history version of the Research Diagnostic Criteria27; (3) symptomatological and longitudinal METHOD characteristics of panic disorder, with particular focus on the The sample consisted of 131 outpatients at the Psychiatric course of the illness and on the relationship between panic Institute of the University of Pisa. The subjects came from a attacks and agoraphobic behavior, separation anxiety disorder variety of sources, almost equally divided between self- during childhood according to DSM-III-R criteria, psychosocial referrals, referrals from general practitioners, various medical life events in childhood and preceding the onset of panic specialists, and psychiatrists, and referrals from former patients. disorder, and the presence of fiypochondriasis according to Admission criteria for the study were (1) a diagnosis of panic DSM-III-R criteria. Contrary to DSM-III-R criteria, a diagnosis disorder with or without agoraphobia according to DSM-III-R of hypochondriasis was made even when the hypochondriacal criteria, 23 (2) an absence of severe physical and laboratory concerns involved mostly somatic symptoms of panic attacks. abnormalities, and (3) an absence of any current psychotic Furthermore, we questioned patients with regard to the illnesses disorders. Comorbidity with other anxiety and mood disorders feared most of all. was not an exclusion criterium. All patients were screened by The final section, administered during the remission phase, the two senior psychiatrists (G.P. and C.T.) in face-to-face explored avoidant and dependent personality disorders accord- interviews to ensure that admission criteria were met. The ing to DSM-III-R criteria and the SCID-1I, 2s affective tempera- patients were enrolled in a follow-up study for panic disorder ments diagnosed according to Akiskal and Mallya criteria, 29 and and agoraphobia conducted at the Psychiatric Institute of the premorbid symptoms that had emerged during the period University of Pisa. Patients provided informed consent for preceding the onset of the first panic attack. participation in this research. At the time they were first Premorbid phobic-anxious traits, in our definition, are long- examined, the mean age was 35.6 years (SD, 11.1; range, 12 to lasting features found in the premorbid history of patients, such 69) and 73% were women. as fear or distress in situations from which escape is difficult,