Somatosensory Amplification in Hypochondriasis and Panic Disorder

Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 6, 46±53 (1999) Somatosensory Amplification in Hypochondriasis and Panic Disorder

M. Pilar MartõÂnez1, Amparo Belloch2* and Cristina Botella3 1Department of Personality, Faculty of Psychology, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain 2Department of Personality, Faculty of Psychology, University of Valencia, Avenida Blasco IbaÂnÄez, 21, 46010 Valencia, Spain 3Department of Psychology, Faculty of Human and Social Sciences, Jaume I University, CastelloÂn, Campus de Borriol, 12080 CastelloÂn, Spain

The aim of this study is to explore the differences and similarities of Somatic Amplification (SA) in both panic and hypochondriasis disorders. An additional objective is to validate the Somatosensory Amplification Scale (SSAS) for use in our cultural context. For these purposes, 34 patients (17 with hypochondriasis and 17 with panic disorder; DSM-III-R criteria) completed the following questionnaires: SSAS, State±Trait Anxiety Inventory, Beck Depression Inventory, MMPI Hypochondriasis Scale, Illness Attitude Scales and Illness Behaviour Questionnaire. The SSAS showed a satisfactory internal consistency (Cronbach's a 0.83), and revealed two components: `Internal Stimulus Amplification' and `External Stimulus Amplifica- tion'. No significant differences were observed between patients with hypochondriasis and patients with panic disorder on the SSAS. In both groups the SSAS was associated with health concerns (Illness Attitude Scales). The best predictors of SA were Bodily Preoccupation (Illness Attitude Scales) in the hypochondriasis group, and Depression in the panic disorder group. Copyright # 1999 John Wiley & Sons, Ltd.

INTRODUCTION Barsky, 1992) have proposed Somatosensory Amplification as a hypothesis to explain the genesis Hypochondriasis is one of the most controversial of hypochondriasis. They have suggested that disorders in the history of Psychopathology, but subjects with hypochondriasis have a tendency to only recently has it become an important issue of focus on their somatic sensations, and to experience research. Up to now there have been some new and them as intense, noxious and disturbing. Somatic interesting theoretical proposals about the patho- Amplification style is characterized by three genic nature and the clinical features of this elements (Barsky, 1992): (i) a predisposition towards disorder. From a cognitive approach, Barsky et al. hypervigilance regarding the body, which is associ- (Barsky and Klerman, 1983; Barsky et al., 1988; ated with an augmented self-scrutiny and attention Barsky and Wyshak, 1990; Barsky et al., 1990; to uncomfortable somatic symptoms; (ii) a propensity to select and focus upon some weak and *Correspondence to: Prof. Amparo Belloch, Departamento de Personalidad, Facultad de Psicologia, Avda Blasco IbaÂnÄez, 21, infrequent physical sensations and (iii) a tendency 46010 Valencia, Spain. to consider these sensations as being dangerous, as well as being signs of a disease. This same author Contract grant sponsor: Conselleria de Cultura, EducacioÂ i CieÁncia, Generalitat Valenciana (Spain). proposes that the concept may be useful in under- Contract grant number: DOGV 1885. standing the physical and psychological disorders

CCC 1063±3995/99/010046±08$17.50 Copyright # 1999 John Wiley & Sons, Ltd. Somatosensory amplification 47 in which bodily symptoms are not completely reliability (internal consistency) of the Spanish related to the actual medical condition. He also version of the SSAS in order to be completely suggests that Amplification could be considered a confident about its use in our context. pathogenic factor in hypochondriasis, and, moreover, it may be a non-specific characteristic of some mental disorders with physical symptomatology METHOD (e.g., depressive disorder, panic disorder). In addition it may play a significant role in the Subjects and Procedures non-pathological and transient process of somatization which is secondary to stressful events, and, The study was carried out in several Mental finally, it may explain the differences in the Outpatients Units in Valencia and CastelloÂn physical symptoms shown by sufferers of the (Spain). For this purpose all those patients consecu- same medical disease (e.g., rheumatoid arthritis, tively admitted during a two year period to the cardiac arrhythmia). units were assessed by one of the members (clinical Barsky et al. (1990) have constructed the Somato- psychologist or psychiatrist) of the clinical staff. The sensory Amplification Scale (SSAS) to assess 56 patients that, according to the clinical judgement sensitivity to unpleasant but benign somatic sensa- of the psychologist/psychiatrist, had hypochondria- tions, and have applied different versions of this cal concerns or panic attacks were submitted to the instrument to persons with hypochondriasis first author (M. P. M.) for a screening interview. The (Barsky et al., 1990) and to general medical out- hypochondriasis patients were screened using a patients (Barsky and Wyshak, 1990), observing that modified version of the Structured Diagnostic Amplification is related to hypochondriacal symp- Interview for Hypochondriasis (Barsky et al., 1992) toms. that yielded a DSM-III-R (APA, 1987) diagnosis; the The concept of Somatosensory Amplification panic patients were examined using the Structured shares many resemblances to the explanatory Clinical Interview for DSM-III-R (panic disorder models developed by Salkovskis, Clark and co- section) (Spitzer et al., 1990).* For all patients the workers for hypochondriasis disorder (Salkovskis, fulfilment of the following supplementary criteria 1989; Warwick, 1989; Warwick and Salkovskis, was also required: age range from 18 to 65 years, no 1989; 1990; Salkovskis and Clark, 1993) and for history of alcoholism or drug addiction and current panic disorder (Clark, 1986; 1988; Salkovskis, 1988). absence of a diagnosed physical illness. Those These two models propose the same nuclear subjects who met DSM-III-R criteria for hypochon- element for both disorders: the tendency to driasis or for panic disorder as well as fulfilling the catastrophically misinterpret bodily symptoms; other criteria listed above were asked to participate that is, the propensity to assess them as unequivocal in a psychological research project about health signs of malignant organic processes. The two preoccupations. After their acceptation, they had models also emphasize hypervigilance and focal- another clinical interview (DSM-III-R criterion ization of attentional resources upon the body based) conducted by M. P. M. to rule out the because both components are involved in main- comorbidity between panic disorder and hypochon- taining the hypochondriacal and panic symptoms. driasis as well as to examine the presence of other From this theoretical perspective, it could be mental disorders in Axis I. argued that amplification plays the same role in Finally, 34 patients were selected: 17 patients maintaining the symptoms in both panic and with hypochondriasis (four men, 13 women; age hypochondriasis. range 20±50 years) and 17 patients with panic Taking into account the preceding issues, the disorder (five men, 12 women; age range 18± aims of the present study were, first of all, to 49 years). Most of patients had a middle or low observe the presence of Somatic Amplification in educational level. There was not a current comor- hypochondriasis and in panic disorder; secondly, to bidity between panic disorder and hypochondriasis analyse the relationship between Amplification and in the selected patients. All of them had panic other psychopathological variables (Anxiety, disorder or hypochondriasis as the main Axis I Depression, Somatic Symptoms, Illness Attitudes disorder. Moreover, both groups of subjects had and Illness Behaviours) and thirdly, to explore some symptoms of an anxiety disorder (e.g., which of the above mentioned variables best predicts the tendency to amplify bodily sensations. *When that study was started, we did not have the definitive An additional objective was to examine the Spanish version of DSM-IV.

Copyright # 1999 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 6, 46±53 (1999) 48 M. P. MartõÂnez et al. generalized anxiety disorder, social phobia, obses- instrument includes 29 items divided into sive±compulsive disorder), mood disorder (e.g., nine subscales: Worry about Illness (W), Con- major depression, dysthymia) and somatoform cern about Pain (CP), Health Habits (HH), disorder (e.g., somatization disorder). However, Hypochondriacal Beliefs (HB), Thanatophobia none of the patients fulfilled all the required (Th), Disease Phobia (DP), Bodily Preoccupa- DSM-III-R criteria for another anxiety, mood or tions (BP), Treatment Experience (TE) and somatoform disorder. Effects of Symptoms (ES). Each item is evalu- ated on a five-point scale ranging from 0 (`no') to 4 (`most of the time'). To be used in our Instruments context, the questionnaire was first translated into Spanish by the authors and then translated The participants fulfilled the Spanish adaptations of back into English by an English native person the following self-report instruments: in order to ensure that the meaning of the items (i) State±Trait Anxiety Inventory, STAI (Spielberger was not altered or lost in the process. The IAS et al., 1970). This is a 40-item questionnaire has shown an adequate internal consistence which assesses anxiety trait (20 items) and (Cronbach's alpha) (a 0.87 in hypochondria- anxiety state (20 items). For the anxiety trait, sis; a 0.91 in panic disorder and a 0.90 in mean values (SD) of 20.2 (8.9) for males and 25 normal people) (MartõÂnez, 1997). (10) for females had been reported in Spanish (v) Illness Behaviour Questionnaire, IBQ (Pilowsky normal samples (Seisdedos, 1988), and of 28 and Spence, 1983). This questionnaire assesses (10.6) in subjects diagnosed as having an the attitudes that suggest dysfunctional modes anxiety disorder (Spielberger et al., 1970); for of responding to one's state of health (Pilows- the anxiety state, mean values (SD) of 20.5 ky, 1971). The IBQ includes 62 items (two (10.5) for males and 23.3 (11.9) for females in response alternatives: `yes' or `no'), grouped Spanish normal samples (Seisdedos, 1988), and into seven factors: General Hypochondriasis of 29 (11.6) in subjects diagnosed as having an (GH), Disease Conviction (DC), Psychological anxiety disorder (Spielberger et al., 1970). versus Somatic Focusing (P/S), Affective (ii) Beck's Depression Inventory, BDI (Beck et al., Inhibition (AI), Affective Disturbance (AD), 1979). This is a well-validated questionnaire Denial (D) and Irritability (I). The IBQ also has which is widely used as a screening instrument an index (Whiteley Index, WI) composed of for depression. Subjects scoring above 15 are 14 items that assess hypochondriacal attitudes. usually considered as having clinical depres- For this study we used the IBQ Spanish sion, whereas subjects scoring from 9 to 14 are adaptation of Ballester and Botella (1993). The considered as subclinical or mildly depressed, IBQ has shown an acceptable internal consist- and subjects scoring 8 or less are classified as ency (Cronbach's alpha) (a 0.74 in hypo- non-depressed (Conde et al., 1976; Bumberry chondriasis; a 0.68 in panic disorder and et al., 1978). a 0.78 in normal people) (MartõÂnez, 1997). (iii) Minnesota Multiphasic Personality Inventory, (vi) Somatosensory Amplification Scale, SSAS (Barsky Hypochondriasis Scale (Hs) (Hathaway and et al., 1990). The SSAS evaluates sensitivity to McKinley, 1967). This questionnaire assesses mild bodily sensations that are uncomfortable abnormal preoccupation about bodily func- and unpleasant but non-pathological (Barsky tions (Hathaway and McKinley, 1967). The Hs et al., 1990). This instrument consists of ten scale contains 33 true±false statements. In a statements that are estimated on a five-point recent study Edelmann and Holdsworth (1993) scale ranging from 1 (`not at all') to 5 suggest that this instrument `seems to assess (`extremely'). Its translation into Spanish and actual somatic awareness and its use as a back into English was made following the measure of hypochondriacal beliefs and procedure used in the Illness Attitude Scales attitudes is questionable' (p. 370). On the mentioned above. basis of this suggestion, we used the Hs scale as a symptom somatic checklist. All the patients were individually tested by one (iv) Illness Attitude Scales, IASS (Kellner, 1986). The of the authors at the Outpatient Service in two IASS evaluate the attitudes, fears and beliefs sessions conducted on two consecutive days. The involved with hypochondriasis and abnormal order of presentation of the questionnaires was illness behaviour (Kellner, 1987). This randomized for each patient.

Statistical Analyses panic disorder in their scores of SSAS (Table 1). This result indicates that both groups are similar in In order to examine the differences between this clinical feature, and for this reason we consider hypochondriasis and panic disorder groups in the the two samples together in order to examine the SSAS, Student's t-test for independent samples was reliability of the scale. The SSAS shows a good performed. In order to prevent a Type II error we internal consistency (Cronbach's a 0.83), and this calculated that a sample of 17 subjects in each suggests that it could be reliably used to measure group would have 80% power to detect a standard- the intensification of bodily sensations in our ized difference of 1.2 (two-group t-test, p 5 0.01, samples. The item±total correlations were moder- two tailed) (Altman, 1991). To analyse the internal ately high ranging from 0.37 (item 2) to 0.72 (item 4). consistency of the SSAS, Cronbach's alpha coeffi- Factor analysis revealed two components explain- cient was used. The existence of separate dimen- ing the 58.3% of the total variance. The first factor sions in the SSAS was explored by a factor analysis was the most relevant (variance explained 41.1%), (principal components, varimax rotation, and included items related to sensations of the body eigenvalue 5 1 and saturation 5 0.50). The items (items 3, 4, 6, 8, 9 and 10); for this reason it was to sample ratio (3.4:1) was within the acceptable labelled `Internal Stimulus Amplification'. The values for the use of exploratory factor analysis second factor explained a minor proportion of (Kline, 1987). Pearson correlations were calculated variance (17.2%) and was composed of items in hypochondriasis and panic disorder samples to referring to environmental variables such as analyse the relationships between Amplification temperature, sound and air pollution (items 1, 2, 5 and the other psychometric variables considered. and 7). This component was named `External On the basis of the correlation indexes multiple Stimulus Amplification'. regression analyses (stepwise method) were carried In a previous study (MartõÂnez et al., 1996) we out to determine for each group the predictive value found that hypochondriasis and panic disorder of several psychometric indexes in Somatic Ampli- subjects did not differ in Anxiety, Depression and fication. The independent variable to sample ratios Somatic Symptoms, but showed differences on in these analysis were calculated on the basis of the several measures of Illness Attitudes and Beha- square root of the sample size (3:17) (Altman, 1991). viours. On the basis of these results we separately Analyses were done using the SPSS 6.01 for PCs. explored in each sample the correlational pattern between Amplification and the other clinical vari- RESULTS ables considered. Table 2 shows the Pearson correlation coefficients No significant differences were obtained between obtained. In the hypochondriasis group, SSAS patients with hypochondriasis and patients with (total score) was significantly related to some IAS

Table 1. Comparison of Somatosensory Amplification Scale scores of hypochondriasis and panic disorder patients

Somatosensory Amplification Scale Hypochondriasis Panic disorder t* (N 17) (N 17) Mean (SD) Mean (SD) 1. When someone else coughs, it makes me cough too 1.52 (0.94) 1.52 (1.00) 0.00 2. I can't stand smoke, smog, or pollutants in the air 2.88 (1.45) 2.29 (1.40) 1.20 3. I am often aware of various things happening within my body 3.58 (1.17) 3.47 (0.94) 0.32 4. When I bruise myself, it stays noticeable for a long time 2.58 (1.54) 2.41 (1.22) 0.37 5. Sudden loud noises really bother me 3.47 (1.41) 3.47 (1.46) 0.00 6. I can sometimes hear my pulse or my heartbeat throbbing in 3.35 (1.45) 3.23 (1.20) 0.26 my ear 7. I hate to be too hot or too cold 2.70 (1.26) 3.23 (1.30) 1.20 8. I am quick to sense the hunger contractions in my stomach 2.82 (1.33) 2.35 (1.27) 1.05 9. Even something minor, like an insect bite or a splinter, really 2.52 (1.46) 2.52 (1.12) 0.00 bothers me 10. I have a low tolerance for pain 3.05 (1.43) 2.94 (1.02) 0.27 Total 28.52 (7.88) 27.47 (8.40) 0.38

*No Student's t-test was significant.

Table 2. Pearson correlations between Somatosensory Amplification Scale (SSAS) and psychological variables, in hypochondriasis and panic disorder patients

Variable Hypochondriasis (N 17) Panic disorder (N 17)

SSAS SSAS

ESA ISA Total ESA ISA Total State Anxiety (STAI-S) 0.24 0.18 0.26 0.04 0.25 0.12 Trait Anxiety (STAI-T) 0.03 0.38 0.30 0.31 0.36 0.36 Depression (BDI) 0.14 0.48* 0.46 0.58* 0.68*** 0.69*** Somatic Symptoms (Hs, MMPI) 0.30 0.37 0.45 0.49* 0.54* 0.56* Worry about Illness (W, IAS) 0.25 0.28 0.34 0.27 0.32 0.32 Concern about Pain (CP, IAS) 0.02 0.61** 0.52* 0.39 0.56* 0.52* Health Habits (HH, IAS) 0.56* 0.49* 0.66*** 0.31 0.34 0.35 Hypochondriacal Beliefs (HB, IAS) 0.39 0.42 0.53* 0.46 0.58* 0.57* Thanatophobia (Th, IAS) 0.29 0.36 0.43 0.54* 0.47 0.54* Disease Phobia (DP, IAS) 0.09 0.15 0.17 0.49* 0.73*** 0.67*** Bodily Preoccupations (BP, IAS) 0.20 0.74*** 0.71*** 0.18 0.28 0.26 Treatment Experience (TE, IAS) 0.40 0.35 0.47 0.50* 0.53* 0.56* Effects of Symptoms (ES, IAS) 0.35 0.42 0.51* 0.22 0.31 0.29 General Hypochondriasis (GH, IBQ) 0.27 0.38 0.44 0.52* 0.57* 0.59* Disease Conviction (DC, IBQ) 0.55* 0.18 0.40 0.09 0.40 0.28 Psychological versus Somatic 0.07 0.21 0.21 0.10 0.13 0.02 Focusing (P/S, IBQ) Affective Inhibition (AI, IBQ) 0.16 0.53* 0.51* 0.22 0.18 0.21 Affective Disturbance (AD, IBQ) 0.41 0.29 0.43 0.12 0.21 0.18 Denial (D, IBQ) 0.00 0.30 0.25 0.25 0.05 0.09 Irritability (I, IBQ) 0.37 0.60** 0.67*** 0.00 0.40 0.23 Whiteley Index (WI, IBQ) 0.31 0.08 0.21 0.34 0.30 0.35

*p 5 0.05; **p 5 0.01; ***p 5 0.005; ESA, External Stimulus Amplification; ISA, Internal Stimulus Amplification. scales (Concern about Pain, Health Habits, Hypo- variables significantly related to the dependent chondriacal Beliefs, Bodily Preoccupations and variables was greater than three, we chose those Effects of Symptoms), and also to two IBQ with the highest correlation coefficients. The results emotional factors (Affective Inhibition and Irrit- are shown in Table 3. ability). In the panic disorder subjects, the SSAS For the multiple regression analysis of the SSAS was related to Depression, Somatic Symptoms, (total score) in the hypochondriasis group the several components of the IAS (Concern about independent variables were Health Habits, Bodily Pain, Hypochondriacal Beliefs, Thanatophobia, Preoccupations (both from the IAS scales) and Disease Phobia and Treatment Experience) and Irritability (from the IBQ). In the panic group the General Hypochondriasis of the IBQ. These same independent variables were Depression (BDI), correlation patterns were observed in the two Disease Phobia (from the IAS) and General samples when the Ìnternal Stimulus Amplification' Hypochondriasis (from the IBQ). In the patients factor was considered. However, the Èxternal with hypochondriasis, Bodily Preoccupations was Stimulus Amplification' factor showed less correla- the best predictor (R2 0.50). However, in the tion with the other measures. panic group the best predictor was BDI (R2 0.47). Six regression analyses were performed taking For the Èxternal Stimulus Amplification' into account three dependent variables (SSAS total analysis, the following variables were entered as score, Èxternal Stimulus Amplification' and independent in the hypochondriasis group: Health Ìnternal Stimulus Amplification') in each one of Habits (from the IAS) and Disease Conviction the two groups of patients. In all these analyses, the (from the IBQ). In the panic group the independent variables that showed significant relationships with variables considered were Depression (BDI), these dependent variables in the panic group and/ Thanatophobia (from the IAS) and General Hypo- or in the hypochondriasis group were considered as chondriasis (IBQ). In the hypochondriasis group independent variables. When the number of only Health Habits (from the IAS) entered the

Table 3. Predictors of Somatosensory Amplification in hypochondriasis and panic disorder patients

Dependent variable Hypochondriasis (N 17) Panic disorder (N 17)

(Step) Independent bR2 F (Step) Independent bR2 F variable variable Amplification 1. Bodily Preoccupations 0.71 0.50 15.41*** 1. Depression (BDI) 0.69 0.47 13.77*** (Total, SSAS) (BP, IAS) External Stimulus 1. Health Habits 0.56 0.32 7.17* 1. Depression (BDI) 0.58 0.33 7.70* Amplification (HH, IAS) (ESA, SSAS) Internal Stimulus 1. Bodily Preoccupations 0.74 0.55 18.81*** 1. Disease Phobia 0.73 0.53 17.56*** Amplification (BP, IAS) (DP, IAS) (ISA, SSAS)

*p 5 0.05; **p 5 0.01; ***p 5 0.005. b and F values are those obtained in the last step. analysis (R2 0.32), but in the panic patients the Regarding the possibility that Amplification variable was BDI (R2 0.33). could be a characteristic of both hypochondriasis In the analysis of `Internal Stimulus Amplifica- and panic disorder, our results show that there was tion' the following were considered as independent no significant differences between these two groups variables for the hypochondriasis group: Concern of patients. In order to explain this data, four About Pain, Bodily Preoccupations (both from the arguments could be suggested. The first is related to IAS) and Irritability (from the IBQ). In the panic the psychometric properties of the Somatosensory group, the independent variables were Depression Amplification Scale: the scale contains only ten (BDI), Disease Phobia (from the IAS) and General items, and its construct validity is not well estab- Hypochondriasis (from the IBQ). In the hypochon- lished. Somatosensory Amplification is conceived driasis group, Bodily Preoccupations (IAS) was the as a cognitive±perceptive style that includes three only predictor (R2 0.55), whereas in the panic main elements: bodily hypervigilance, selection and group it was Disease Phobia (IAS) (R2 0.53). focus on the somatic symptoms and misinterpreta- tion of physical sensations. However, the SSAS only assesses the first two aspects, leaving out the DISCUSSION domain related to the catastrophic interpretations. A second argument to explain the absence of The general purpose of this study was to investigate differences in Amplification between hypochon- the role of Somatic Amplification in those psycho- driasis and panic disorder is derived from the logical disorders characterized by concerns about amplification conceptualization proposed by Barsky non-pathological physical symptoms (as occurs in (1992). From this approach, the somatic style occurs hypochondriasis), as well as in other disorders in in both conditions, even though it may play a which these types of concern are secondary (as different role in each one of them (etiopathogenic occurs in panic disorder). for hypochondriasis and secondary for panic). We The results of the psychometric characteristics of think that this role might not be relevant enough to the Spanish version of the Somatosensory justify the hypothetic existence of differences on this Amplification Scale indicated a good internal parameter between the two disorders. consistency, and supports its use as a reliable A third argument to explain the similarities in the measure of sensitivity to benign bodily sensations. SSAS scores between hypochondriasis and panic The reliability index was similar to that obtained in disorder patients proposes that these patients differ the SSAS original version in which the Cronbach's in the type of bodily sensation that they amplify alpha was 0.82 (Barsky et al., 1990). Moreover, our (symptoms not associated with autonomic arousal results revealed that the scale contains two separate versus symptoms associated with autonomic domains: the first includes a tendency to acutely arousal, according to the cognitive model of perceive external stimulus, and the second was Salkovskis and Clark, 1993) but this divergence related to a lowered perceptual threshold for the cannot be appreciated using this scale given the detection of interoceptive signs. non-specific nature of its items.

Our second objective was to explore the relation- and found that the first group differed from the ships between Somatic Amplification and other second in not having spontaneous panic attacks or clinical indexes. We have found a similar correla- agoraphobic symptoms, predominance of hypo- tional pattern to that obtained by Barsky's group chondriacal symptoms, sex ratio favouring men which demonstrates the presence of Amplification and genetic and environmental factors involved in in hypochondriasis. For example, Barsky and the development of the disorder. Barsky et al. (1994) Wyshak (1990) in a study with 177 outpatients have reported that the subjects with `pure' hypo- found significant correlation coefficients between chondriasis compared with patients with `pure' hypochondriacal symptomatology and Amplifica- panic disorder were more hypochondriacal, somat- tion. Moreover, we have also found some discre- ized and disabled and showed less satisfaction with pancies between the two groups of patients in their their medical care; they had more symptoms of correlational patterns. The SSAS was significantly somatization and generalized anxiety disorders and related to Depression and Somatic Symptoms in the fewer symptoms of major depression and phobias panic disorder group only. In contrast, both groups and their physicians rated them as more demanding of patients showed relationships between Amplifi- and help rejecting. cation and preoccupation about health (e.g., con- In conclusion, our results, and the studies cerns about painful sensations, beliefs about having mentioned above, show that hypochondriasis and a serious organic illness) when the Illness Attitude panic disorder share many clinical features but also Scales were used. However, when the Illness they have their own particular characteristics. It is Behaviour Questionnaire was used, this pattern possible that the matter would be to determine was not clearly observed. These results suggest that whether these differences are important enough to the IAS is a better instrument than the IBQ to assess justify the conceptualization of both disorders as hypochondriacal concerns. In relation to the two separate entities. This topic seems to be relevant factors of the SSAS, we observed that the Ìnternal regarding the nosological status of hypochon- Stimulus Amplification' factor was the most clearly driasis. In this sense, Salkovskis et al. (1990; involved in the phenomenology of both hypochon- Salkovskis and Clark, 1993) have suggested that it driasis and panic disorder. This result was in the may be more appropriate to conceptualize hypo- expected direction because the main focus of chondriasis as an anxiety disorder, and, further- interest for these patients is their own bodies. more, Schmidt (1994) has proposed that panic Regarding to the third objective of the study, that disorder could be classified as a variety of is, the analysis of the predictive value of some hypochondriasis. psychological variables in the amplification style, we obtained the following results. Only a single variable entered the analyses performed. In hypochondriasis the best predictor of Amplification was ACKNOWLEDGEMENT Bodily Preoccupations (BP, IAS), for both the total score of the SSAS and the Ìnternal Stimulus This study was supported by a grant (DOGV Amplification' factor. However, Health Habits number 1855, 20 October 1992), from the Consel- (HH, IAS) was the best predictor for the Èxternal leria de Cultura, EducacioÂ i CieÁncia, Generalitat Stimulus Amplification' factor of the SSAS. In panic Valenciana (Spain). disorder the main predictor of Amplification (for both the total score and the Èxternal Stimulus Amplification' factor), was Depression (BDI), but for the Ìnternal Stimulus Amplification' factor REFERENCES Disease Phobia (DP, IAS) was the best predictor. Altman, D. G. (1991). Practical Statistics for Medical However, these results are difficult to generalize Research. London: Chapman and Hall. given the small size of our sample, and so further American Psychiatric Association (APA). (1987). Diag- exploration with larger samples of subjects are nostic and Statistical Manual of Mental Disorders, 3rd rev. needed. edn. Washington, DC: APA (Spanish version. (1998), There are some studies that have explored the Barcelona: Masson). similarities and differences between hypochon- Ballester, R. and Botella, C. (1993). Perfil de conducta de enfermedad en pacientes con crisis de angustia. AnaÂl. driasis and panic disorder. Noyes et al. (1992) ModificacioÂn Conducta, 19, 233±265. compared subjects with illness phobia (a subtype of Barsky, A. J. (1992). Amplification, somatization, and the hypochondriasis) and subjects with panic disorder somatoform disorders. Psychosomatics, 33, 28±34.

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