A Comparison of Patients With lllness Phobia and Panic Disorder RUSSELL NOYES, JR., M.D. ROBERT
B.
WESNER, M.D.
MARY M. FISHER, M.A.
Fourteen subjects with illness phobia. a subtype of hypochondriasis. were compared with an equal number of subjects with panic disorder who had been matched for age and sex. The illness phobic subjects differed from panic subjects in not having spontaneous panic attacks or agoraphobic symptoms. the characteristic features ofpanic disorder. The onset ofillness phobia was related to experience with illness in half the subjects. Half of the illness phobic subjects also had family histories ofanxiety disorders. The results suggest that illness phobia is distinct from panic disorder and that it is a disorder in which em,jronmental and genetic factors are etiologically important.
I
llness, because it carries with it the threat of discomfort, disability, and death, is a natural object offear. Consequently, it is not unexpected to find that fear of illness and illness phobia are common in the general population. According to Agras et al.,' 3.1 % of the residents of Burlington, Vermont, were phobic about illness or injury, accounting for 42% of the phobia disorders in that community. Given the frequency of this disturbance, it is surprising that so few case series have been described and that relatively little information concerning this phobia is available. 2-4 In the current classification (DSM-III-R 5 ), illness phobia is subsumed under the heading of hypochondriasis. However, a number of authors have suggested that the disorder be given independent status. 6 •7 According to Marks,7 for example, illness phobia represents a focal form of hypo-
Received November 6.1990; revised March 25.1991; accepted April 1\, 1991. From the Department of Psychiatry. University of Iowa. College of Medicine. Address reprint requests to Dr. Noyes. 500 Newton Road. Iowa City. IA 52242. Copyright © 1992 The Academy of Psychosomatic Medicine.
92
chondriasis. He states that hypochondriasis is characterized by fears concerning multiple bodily symptoms but that, when fear is persistently focused on a single symptom or illness, the term illness phobia or nosophobia (Greek nosos (disease] + phobas [fear)) is appropriate. 2 If illness phobia is to achieve separate status within the diagnostic nomenclature, it will be necessary to show that the disorder can be distinguished from closely related disturbances. In addition to hypochondriasis, these include panic disorder with agoraphobia, obsessive-compulsive disorder, and major depression. We previously observed prominent illness phobic or hypochondriacal features in patients with panic disorder with agoraphobia,s a finding subsequently confirmed by Fava et al. 9 I1Iness phobic symptoms are often prominent in patients with major depressive disorder; in that instance they usually fluctuate with the symptoms of depression and disappear when the depressive illness remits. Obsessive-compulsive patients sometimes develop obsessions regarding illness or injury. The ruminations of illness phobics resemble obsessions, except that little sense of resisPSYCHOSOMATICS
Noyes et al.
tance accompanies them, and other obsessive compulsive phenomena are rarely present. 7 In this report we describe a series of patients with illness phobia and compare them to a matched series of patients with panic disorder. We then consider the implications of our findings for the classification of illness phobia. METHODS Subjects with illness phobia were recruited for this study via the news media. After initial screening by telephone, they were personally interviewed and given a series of questionnaires. Subjects were screened using the Structured Clinical Interview for DSM-III-R,IO and those who met DSM-III-R criteria for hypochondriasis were included, provided they had no preexisting psychiatric illness. 5 One of the investigators gave the subjects a structured interview designed to elicit demographic and clinical information. In addition, subjects completed the Illness Behavior Questionnaire," the Symptom Checklist-90 (SCL90),12 the Barsky Amplification Scale,I3 the Fear Questionnaire;4 the Personality Diagnostic Questionnaire (PDQ),15 the Parental Bonding Instrument,16 and the Illness Concerns Scale. 17 The last is an 18-item, self-rated questionnaire designed to measure symptoms of illness phobia (Appendix A). In addition to items from the Whiteley Index, it contains a number of items dealing with reassurance-seeking and avoidant behavior. Each item is rated on a five-point scale (0 [absent] to 4 [extreme]). No testing of the reliability or validity of this scale has been completed. Fourteen illness phobic subjects, including eight men and six women participated in this study. The mean age (±SD) of subjects was 40.6±13.6 years. One subject also met criteria for panic disorder, and another had previously had spontaneous panic attacks; in both instances, however, illness phobia was the predominant disturbance. One additional subject had obsessions and compulsions, but, here again, illness phobia dominated the clinical picture. Two subjects gave histories of alcohol abuse (one of these also had VOLUME 33· NUMBER I • WINTER 1992
abused drugs), and one other had a history of major depression. All of these disturbances began after the onset of illness phobia. Fourteen panic disorder subjects matched for age (within 5 years) and sex also were obtained through the news media. These subjects were selected at random from a larger sample that had been recruited for a treatment study. Each had been screened using the Structured Clinical Interview for DSM-III-R IO and met DSM-III-R criteria for panic disorder. 5 In addition, these subjects were required to have had at least one panic attack per week (four symptoms) for 4 weeks before the start of the study. Panic disorder subjects included eight men and six women with a mean age of 40.1± 13.2 years. These subjects completed most of the same questionnaires that the illness phobic subjects completed. Fourteen subjects who never had been psychiatrically ill and who were matched for age (within 5 years) and sex with the illness phobic subjects also were recruited through the news media. Each was screened using the Schedule for Affective Disorders and Schizophrenia, Lifetime Version. 18 These controls included eight men and six women with a mean age of 39.6±13.0 years. They also completed the same questionnaires. The demographic and illness characteristics of the illness phobic subjects were compared with the demographic and illness characteristics of another series of 82 panic disorder subjects who had been assessed using a very similar instrument. These subjects represented a consecutive series seen in a psychiatric clinic and given DSMIII-R diagnoses. This group included 35 men and 47 women with a mean age of 37.9±12.7 years. Detailed information about these subjects was reported previously. 19 Comparisons between continuous variables were examined using Student's t tests and between categorical variables by means of chisquare tests. RESULTS The frequency with which illness phobic subjects reported characteristics elicited by interview is shown in Table I. All reported the fear of having 93
Illness Phobia and Panic Disorder
or of developing serious illness, the most common being cancer and heart disease. The fear was usually specific, involving one or, in some instances, more than one illness, such as colon cancer, brain tumor, etc. In some, the feared illness had changed over time; four indicated that they had feared AIDS at one time or another. Although a belief that they actually had the disTABLE 1. Percentage or illness phobia subjects (n = 14) who endorsed items contained in a structured interview designed by the author Item
Percentage
I. Fear of having or developing serious illness 2. Preoccupation with fear or symptoms 3. Recognition that fear is unfounded 4. Persistent seeking of reassurance 5. Lack of medical evidence for illness 6. Bodily sensations prompt concern 7. Somatic symptoms a focus of worry 8. Avoidance of reminders about illness 9. Fear persistent despite reassurance 10. Examination of body for signs of illness II. Health concerns not taken seriously 12. Conviction about existing illness an
100.0 92.9 92.9 92.9 92.9 85.7 78.6 78.6 76.9a 7 \.4 53.8' 42.9
= 13
TABLE 2.
ease was sometimes strong, none of the illness phobic subjects reported a persisting conviction about this. In fact, none of these patients suffered from known major illness, and almost all recognized the unreasonable nature of their fear. Most of the illness phobic subjects reported that a fear response was cued by physical symptoms, although a few had no somatic symptoms. In these cases the fear itself, together with its cognitive component, was the focus of preoccupation. Most subjects reported vigilance toward bodily sensations, and many indicated that they repeatedly examined their bodies for signs of illness. The fear persisted despite reassurance, but about half felt that their concerns about illness had not been taken seriously by doctors or others. In fact, the effect of their fear upon medical care was often substantial. Out of fear, some subjects avoided going to the doctor, whereas others repeatedly sought reassurance from physicians. The demographic and illness characteristics of illness phobic and panic disorder subjects are shown in Table 2. The majority of illness phobics were men, whereas panic disorder subjects were predominantly women. The age of onset of illness phobia was similar to that of panic disorder, but the onset distribution was skewed; the median
Demographic and illness variables ror subjects with illness phobia and panic disorder
Variable Age (mean) Sex (% women) Age of onset (mean) Duration of illness (mean years) Type of onset (% sudden) Precipitating events (% present) Course (% remissions) Severity of symptoms (% severe) Secondary depression (%) Secondary alcohol abuse (%) Work impairment (%) Marital impairment (%) Social impairment (%) Neurotic traits in childhood (%) Phobias in childhood (%)
Illness Phobia n = 14
Panic Disorder n =82
P
40.6 42.9 23.3 17.6 64.3 71.4 42.9 35.7 7.1 21.4 0.0 18.2 0.0 7.1 28.6
37.9 57.3 26.2 10.7 51.9 68.3 20.7 52.4 61.0 20.7 22.2 42.6 35.4 22.2 24.7
NS NS NS NS NS NS NS 0.05 0.001 NS NS 0.05 0.01 NS NS
NOle: P values are for chi-square tests with one degree of freedom, except for comparisons of age. age of onset, and duration, which were examined using Student's I· tests. NS = nOI significant.
94
PSYCHOSOMATICS
Noyes et al.
age of onset for illness phobia was 21. Fewer illness phobic subjects reported severe symptoms, and more of these subjects had experienced remissions. Also, fewer illness phobics had experienced secondary depression. Lastly, fewer of the illness phobics reported social impairment associated with their illness than did the panic disorder subjects. Table 3 shows a comparison between normal, illness phobic, and panic disorder subjects on hypochondriacal, phobic, and anxious symptoms as measured by three self-rating inventories. Illness phobics reported more severe hypochondriacal symptoms as measured by the Whiteley Index (a subscale of the Illness Behavior Questionnaire), and blood/injury phobia symptoms, as measured by the Fear Questionnaire, than did panic disorder subjects. However, panic disorder subjects reported more severe social and agoraphobic symptoms as measured by the Fear Questionnaire, and anxiety and somatic symptoms, as assessed by the SCL-90. Also, the overall level of symptoms on the SCL-90 was higher for the panic disorder subjects than for illness phobic subjects. The mean Barsky Amplification Scale score for illness phobics was 25.9±6.7; for normal sub-
jects it was 20.5±7.3 (P = 0.06). Also, the mean Illness Concerns Scale score was 37.3±15.6 for illness phobics and 6.ltlO.0 for normal subjects (P < 0.001). Positive family histories (first-degree relatives) for anxiety disorders were found in 50.0% of illness phobics and 52.8% of panic disorder subjects. Of the illness phobics, 21.4% had a first-degree relative with illness phobia. In addition, 7.1 % of illness phobic subjects had family histories of panic disorder, compared to 41.7% of panic disorder subjects. Family histories of mood disorder were found in 35.7% and 15.3%, respectively, and family histories of alcohol abuse were found in 21.4% and 36.1 %, respectively. Illness phobic and panic disorder subjects differed little with respect to separation from a parent before age 15 (35.7% vs. 32.0%), parental overprotection (14.3% vs. 20.5%), or poor relationship with a parent (57.1% vs. 40.2%). As is shown in Table 4, illness phobic subjects rated their parents as less caring and slightly more protective than normal subjects, but none of these differences were statistically significant. In terms of personality (Table 4), the illness phobic subjects scored higher on impairment of personality functioning (impairment/distress scale of the
TABLE 3. Mean scores on the Whiteley Index. Fear Questionnaire, and Symptom ChKklist-9CJ for normal, illness phobia, and panic disorder subjKts Instrument Whiteley Index Disease phobia Disease conviction Somatic preoccupation Total Fear Questionnaire Blood/injury Agoraphobia Social phobia Total Symptom ChKklist-90 Anxiety Phobia Somatization Total
Normal n = 14
Illness Phobia n= 14
Panic Disorder n = 14
P
0.001 0.001 0.05 NS
0.4 0.2 0.3 1.4
1.9 9.8
0.9 0.6 1.5 4.4
3.6 2.2 5.0 10.8
16.2 5.8 9.3 31.3
9.6 12.7 15.8 38.1
0.02 0.05 0.05 NS
2.0 0.5 4.9 25.4
14.7 3.5 9.9 84.2
18.8 10.9 17.8 119.7
NS 0.001 0.05 0.05
3.5
1.3
NOle: P represents comparisons of illness phobia and panic disorder subjects using Student"s I-tests. NS significant.
VOLUME 33· NUMBER I • WINTER 1992
=not
95
Illness Phobia and Panic Disorder
PDQ) and reported more abnormal personality traits than the normal subjects. Twelve panic disorder subjects scored above the cutoff for one or more personality disorders, compared to eight illness phobics and six normal subjects. Five panic and illness phobic subjects and two normal subjects scored 2 or more on the illness distress scale, indicating impairment in personality functioning. DISCUSSION Our illness phobic subjects were fearful of developing specific diseases, usually some form of cancer or heart disease; thus, their fears were focused on single illnesses and not on multiple symptoms or illness in genera\.7 In addition to concern about specific illnesses, our subjects showed two other features that appeared to distinguish them from patients with hypochondriasis. Most of our patients were more distressed by fear and by anxious thoughts than they were by somatic symptoms. Physical distress was relatively minor and, in a few instances, absent, as Mayou 20 previously observed. Thus, psychological symptoms dominated the clinical picture, and patients tended to characterize their problem as one of fear or fearful thoughts. Consistent with this focus on psychological distress, our patients recognized the unreasonableness of their fear, and any real conviction about being seriously ill tended to be short-lived. They did not believe that TABLE 4.
they were ill, but, rather, they feared the future possibility. Early on, Pilowsky21 identified independent dimensions of disease phobia and disease conviction among hypochondriacal patients, which were later confirmed by Bianchi. 22 Consequently, patients can be expected to vary with respect to these features; as Table 3 shows, disease phobia scores were much higher than disease conviction scores in our illness phobic subjects. We previously observed prominent hypochondriacal or illness phobic features among patients with panic disorder,S and our observations were confirmed by Fava et a\. 9 This prompted our comparison of illness phobic and panic subjects, from which we conclude that these are separate disorders. To begin with, only two of the illness phobic subjects had ever experienced spontaneous panic attacks, and only two reported symptoms of agoraphobia. Also, examination of symptom inventory scores showed that illness phobic and panic subjects had different patterns of symptoms. Among the illness phobics, hypochondriacal symptoms predominated, whereas among the panic subjects, agoraphobic, anxiety, and somatic symptoms dominated the clinical picture. We found that the sex ratio for illness phobia favored men, as did Warwick and Marks4 in their series. This is the reverse of the usual preponderance of women with panic disorder and agoraphobia. The illness phobias we studied seemed c1ear-
Mean scores for normal, illness phobia, and panic disorder subjects on the Personality Diagnostic Questionnaire and Parental Bonding Instrument
Instrument Personality Diagnostic Questionnaire Impairment/distress Unstable cluster Anxious cluster Total
Normal n = 14
Illness Phobia n = 14
Panic Disorder n = 14
P
0.4 5.8 6.4 19.1
1.0 9.5 9.8 28.4
1.5 10.1 14.0 35.0
NS NS NS NS
28.6 10.8 26.6 8.9
23.1 11.5 21.4 13.5
22.6 18.6 17.1 12.0
NS NS NS NS
Parental Bonding Instrument Maternal care Maternal protection Paternal care Paternal protection
Note: P represents comparisons of illness phobia and normal subjects using Student's t-tests. NS = not significant.
96
PSYCHOSOMATICS
Noyes et al.
ly related to environmental precipitants. In fact, 7 of 14 subjects related the onset of their phobia to experience with illness. For four, symptoms began immediately after the development of serious illness in a family member. In addition, one woman developed symptoms after being told that she had an abnormal chest x-ray. Another, a respiratory therapist, developed a fear of throat cancer, following exposure to a patient with this disease. Still another, with an extensive smoking history, developed a fear of lung cancer. This relationship to environmental factors has been noted by previous authors. 2,J.7 However, we did not find evidence that parental attitudes had influenced the development of illness phobia. Our subjects with this disturbance did not report that their parents had been more protective than the parents of normal controls. Therefore, we were not able to confirm Bianchi's observation of greater parental overprotection among psychiatric inpatients with illness phobic features. 3 In terms of possible genetic factors, half of our subjects with illness phobia had positive family histories of anxiety disorders, including three with illness phobia and one each with panic disorder and obsessive-compulsive disorder. Thus, while exposure to illness appeared to be an important factor, inherited vulnerability also may have contributed to the development of this disorder. Based on the study of our patients and a review of previous case series, we drew up the diagnostic criteria shown in Table 5. If illness phobia is to find its way into the psychiatric TABLE S. Criteria for illness phobia developed by the authors. To meet these criteria a patient must show evidence of A through F A. An unreasonable fear that one has. or is about to develop. specific and serious illness B. Persistence of fear despite medical evidence to the contrary C. Vigilance toward. and scanning of. one's body for signs or symptoms of serious illness D. Distress caused by bodily sensations or other cues to serious illness E. Persistent avoidance of external cues to illness and/or seeking of reassurance about health status F. Recognition that one's fear is unfounded
VOLUME 33· NUMBER I • WINTER 1992
nomenclature as a subtype of hypochondriasis, then its distinguishing characteristics must be identified and its predictive validity must be established. The criteria we propose emphasize fear of specific illness, reassurance-seeking behavior, and recognition that the fear is unreasonable. They do not include preoccupation with somatic symptoms or the conviction that one is currently ill. Thus, the fear is focal rather than diffuse. Further, like most phobic patients, illness phobics recognize the unreasonableness of their fear. 7 Psychological rather than somatic symptoms predominate, and reassurance-seeking behavior is the most prominent behavioral manifestation. The picture is quite like that of other phobic disorders, except, as Marks 23 has noted, the object of the phobia is internal and therefore inescapable. The development and testing of criteria for illness phobia will require a number of studies examining the boundaries with overlapping disorders, looking for distinguishing clinical features, unique course and outcome, differing patterns of illness in the family, biological markers (where they exist), and even differences in response to treatment. Clinically it may be important to recognize patients with illness phobia because the disorder appears to be responsive to drug and behavioral treatment. Warwick and Marks4 reported that these patients receive lasting benefit from behavior therapy in the form of exposure plus response prevention. The patients in our study were treated with imipramine for 8 weeks, and all who remained on the drug for 4 weeks or more reported at least moderate improvement. 17 Patients of this kind are infrequently diagnosed despite their heavy utilization of medical care. This is because they present with somatic symptoms and because they are often reluctant to reveal their phobic concerns. Consequently, few patients with illness phobia are treated for their illness, and fewer still are referred to psychiatrists. This situation will only be corrected when more research is done to clearly establish this diagnostic entity and to make clinicians aware of its favorable response to treatment. This study was limited by the smallness of the sample and by the method of recruiting sub97
Illness Phobia and Panic Disorder
APPENDIX A.
Illness Concerns Scale
Name To what extent have you been bothered by the thoughts, feelings, or actions listed below during the past week? I. Worry about your health
2. Fear of serious illness or death 3. Thinking there might be something seriously wrong with your body 4. Thinking you should contact the doctor about how you feel 5. Having to examine your body to see if there might be something wrong 6. Feeling convinced that you are seriously ill despite evidence to the contrary 7. Finding that you think about how you feel a lot of the time 8. Having a lot of physical symptoms thaI might be due to serious illness 9. Avoiding doctors or medical care on account of fear 10. Feeling that your concern about illness may not be realistic II. Worry about changes in your body or appearance 12. Having to avoid objects or activities that might lead to illness or injury 13. Feeling upset by things you hear or read about that remind you of serious illness 14. Finding it hard to distract yourself from how you feel 15. Feeling that people are not taking your concern seriously 16. Having to avoid reminders of serious illness or death 17. Finding it hard to believe the doctor that there is nothing seriously wrong with you 18. Feeling embarrassed about your health worries
Date Not at All
A Little Bit
Somewhat
A Lot
Extremely
0 0 0
2 2 2
3 3 3
4 4 4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
jects. Because the numbers are small, it is difficult to show differences where they might exist or to have confidence in the differences observed. Also, our symptomatic volunteers may have been self-selected for certain types of symptoms and
may have been milder than the series recruited from a clinical population. However, we have demonstrated that small numbers of patients with illness phobia can be recruited from the general population and that they are available for study.
References I. Agras S. Sylvester D. Oliveau 0: The epidemiology of common fears and phobias. Compr Psychiatry 10:151156. 1969 2. Ryle JA: Nosophobia. Journal of Mental Science 94: 117.1948
98
3. Bianchi ON: Origins of disease phobia. Aust N Z J Psychiatry 5:241-257.1971 4. Warwick HMC, Marks 1M: Behavioral treatment of illness phobia and hypochondriasis: a pilot study of 17 cases. Br J Psychiatry 152:239-241, 1988
PSYCHOSOMATICS
Noyes et al.
5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition. Re· vised. Washington. DC. American Psychiatric Association. 1987 6. Kellner R: Somatization and Hypochondriasis. New York. Praeger. 1986. pp 35-38 7. Marks 1M: Fears. Phobias and Rituals. New York. Oxford University Press. 1987. pp 410-415 8. Noyes R. Reich J. Clancy J. et al: Reduction in hypochondriasis with treatment of panic disorder. Br J Psychiatry 149:631-635. 1986 9. Fava GA. Kellner R. Zielezny M. et al: Hypochondriacal fears and beliefs in agoraphobia. J Affective Disord 14:239-244. 1988 10. Spitzer RL. Williams JBW. Gibbon M. et al: Structured Clinical Interview for DSM·III-R-Patient Edition. Washington. DC. American Psychiatric Press. 1990 II. Pilowsky I, Spence ND: Manual for the Illness Behavior Questionnaire (IBQ). 2nd edition. Adelaide. South Australia. Depanment of Psychiatry. University of Adelaide. 1983 12. Derogatis LR: SCL-90: Administration. Scoring and Procedures Manual. Baltimore. MD. Clinical Psychometric Research. Johns Hopkins University School of Medicine. 1977 13. Barsky AJ. Goodson JD. Lane RS. et al: The amplifica-
VOLUME 33· NUMBER I • WINTER 1992
tion of somatic symptoms. Psychosom Med 50:51 0-519. 1988 14. Marks 1M. Mathews AM: Brief standard self-rating for phobic patients. Behav Res Ther 17:263-267. 1979 15. Hyler S. Reider R. Spitzer RL. et al: Personality Diagnostic Questionnaire (PDQ). New York. New York State Psychiatric Institute. Biometrics Research. 1983 16. Parker G. Tupling H. Brown LB: A parental bonding instrument. Br J Med Psychol52: 1-10. 1979 17. Wesner FB. Noyes R: Imipramine an effective treatment for illness phobia. J Affective Disord 22:43-48. 1991 18. Spitzer RL. Endicott J: Schedule for Affective Disorders and Schizophrenia. Lifetime Version. New York. Biometrics Research. 1975 19. Noyes R. Clancy J. Garvey MJ: Is agoraphobia a variant of panic disorder or a separate iliness? Journal ofAnxiety Disordus 1:3-13. 1987 20. Mayou R: The nature of bodily symptoms. Br J Psychi· atry 129:55-60. 1976 21. Pilowsky I: Dimensions of hypochondriasis. Br J Psychiatry 113:89-93. 1967 22. Bianchi GN: Patterns of hypochondriasis: a principal components analysis. Br J Psychiatry 122:541-548. 1973 23. Marks 1M: The classification of phobic disorders. Br J Psychiatry 116:377-386. 1970
99
B.
WESNER, M.D.
MARY M. FISHER, M.A.
Fourteen subjects with illness phobia. a subtype of hypochondriasis. were compared with an equal number of subjects with panic disorder who had been matched for age and sex. The illness phobic subjects differed from panic subjects in not having spontaneous panic attacks or agoraphobic symptoms. the characteristic features ofpanic disorder. The onset ofillness phobia was related to experience with illness in half the subjects. Half of the illness phobic subjects also had family histories ofanxiety disorders. The results suggest that illness phobia is distinct from panic disorder and that it is a disorder in which em,jronmental and genetic factors are etiologically important.
I
llness, because it carries with it the threat of discomfort, disability, and death, is a natural object offear. Consequently, it is not unexpected to find that fear of illness and illness phobia are common in the general population. According to Agras et al.,' 3.1 % of the residents of Burlington, Vermont, were phobic about illness or injury, accounting for 42% of the phobia disorders in that community. Given the frequency of this disturbance, it is surprising that so few case series have been described and that relatively little information concerning this phobia is available. 2-4 In the current classification (DSM-III-R 5 ), illness phobia is subsumed under the heading of hypochondriasis. However, a number of authors have suggested that the disorder be given independent status. 6 •7 According to Marks,7 for example, illness phobia represents a focal form of hypo-
Received November 6.1990; revised March 25.1991; accepted April 1\, 1991. From the Department of Psychiatry. University of Iowa. College of Medicine. Address reprint requests to Dr. Noyes. 500 Newton Road. Iowa City. IA 52242. Copyright © 1992 The Academy of Psychosomatic Medicine.
92
chondriasis. He states that hypochondriasis is characterized by fears concerning multiple bodily symptoms but that, when fear is persistently focused on a single symptom or illness, the term illness phobia or nosophobia (Greek nosos (disease] + phobas [fear)) is appropriate. 2 If illness phobia is to achieve separate status within the diagnostic nomenclature, it will be necessary to show that the disorder can be distinguished from closely related disturbances. In addition to hypochondriasis, these include panic disorder with agoraphobia, obsessive-compulsive disorder, and major depression. We previously observed prominent illness phobic or hypochondriacal features in patients with panic disorder with agoraphobia,s a finding subsequently confirmed by Fava et al. 9 I1Iness phobic symptoms are often prominent in patients with major depressive disorder; in that instance they usually fluctuate with the symptoms of depression and disappear when the depressive illness remits. Obsessive-compulsive patients sometimes develop obsessions regarding illness or injury. The ruminations of illness phobics resemble obsessions, except that little sense of resisPSYCHOSOMATICS
Noyes et al.
tance accompanies them, and other obsessive compulsive phenomena are rarely present. 7 In this report we describe a series of patients with illness phobia and compare them to a matched series of patients with panic disorder. We then consider the implications of our findings for the classification of illness phobia. METHODS Subjects with illness phobia were recruited for this study via the news media. After initial screening by telephone, they were personally interviewed and given a series of questionnaires. Subjects were screened using the Structured Clinical Interview for DSM-III-R,IO and those who met DSM-III-R criteria for hypochondriasis were included, provided they had no preexisting psychiatric illness. 5 One of the investigators gave the subjects a structured interview designed to elicit demographic and clinical information. In addition, subjects completed the Illness Behavior Questionnaire," the Symptom Checklist-90 (SCL90),12 the Barsky Amplification Scale,I3 the Fear Questionnaire;4 the Personality Diagnostic Questionnaire (PDQ),15 the Parental Bonding Instrument,16 and the Illness Concerns Scale. 17 The last is an 18-item, self-rated questionnaire designed to measure symptoms of illness phobia (Appendix A). In addition to items from the Whiteley Index, it contains a number of items dealing with reassurance-seeking and avoidant behavior. Each item is rated on a five-point scale (0 [absent] to 4 [extreme]). No testing of the reliability or validity of this scale has been completed. Fourteen illness phobic subjects, including eight men and six women participated in this study. The mean age (±SD) of subjects was 40.6±13.6 years. One subject also met criteria for panic disorder, and another had previously had spontaneous panic attacks; in both instances, however, illness phobia was the predominant disturbance. One additional subject had obsessions and compulsions, but, here again, illness phobia dominated the clinical picture. Two subjects gave histories of alcohol abuse (one of these also had VOLUME 33· NUMBER I • WINTER 1992
abused drugs), and one other had a history of major depression. All of these disturbances began after the onset of illness phobia. Fourteen panic disorder subjects matched for age (within 5 years) and sex also were obtained through the news media. These subjects were selected at random from a larger sample that had been recruited for a treatment study. Each had been screened using the Structured Clinical Interview for DSM-III-R IO and met DSM-III-R criteria for panic disorder. 5 In addition, these subjects were required to have had at least one panic attack per week (four symptoms) for 4 weeks before the start of the study. Panic disorder subjects included eight men and six women with a mean age of 40.1± 13.2 years. These subjects completed most of the same questionnaires that the illness phobic subjects completed. Fourteen subjects who never had been psychiatrically ill and who were matched for age (within 5 years) and sex with the illness phobic subjects also were recruited through the news media. Each was screened using the Schedule for Affective Disorders and Schizophrenia, Lifetime Version. 18 These controls included eight men and six women with a mean age of 39.6±13.0 years. They also completed the same questionnaires. The demographic and illness characteristics of the illness phobic subjects were compared with the demographic and illness characteristics of another series of 82 panic disorder subjects who had been assessed using a very similar instrument. These subjects represented a consecutive series seen in a psychiatric clinic and given DSMIII-R diagnoses. This group included 35 men and 47 women with a mean age of 37.9±12.7 years. Detailed information about these subjects was reported previously. 19 Comparisons between continuous variables were examined using Student's t tests and between categorical variables by means of chisquare tests. RESULTS The frequency with which illness phobic subjects reported characteristics elicited by interview is shown in Table I. All reported the fear of having 93
Illness Phobia and Panic Disorder
or of developing serious illness, the most common being cancer and heart disease. The fear was usually specific, involving one or, in some instances, more than one illness, such as colon cancer, brain tumor, etc. In some, the feared illness had changed over time; four indicated that they had feared AIDS at one time or another. Although a belief that they actually had the disTABLE 1. Percentage or illness phobia subjects (n = 14) who endorsed items contained in a structured interview designed by the author Item
Percentage
I. Fear of having or developing serious illness 2. Preoccupation with fear or symptoms 3. Recognition that fear is unfounded 4. Persistent seeking of reassurance 5. Lack of medical evidence for illness 6. Bodily sensations prompt concern 7. Somatic symptoms a focus of worry 8. Avoidance of reminders about illness 9. Fear persistent despite reassurance 10. Examination of body for signs of illness II. Health concerns not taken seriously 12. Conviction about existing illness an
100.0 92.9 92.9 92.9 92.9 85.7 78.6 78.6 76.9a 7 \.4 53.8' 42.9
= 13
TABLE 2.
ease was sometimes strong, none of the illness phobic subjects reported a persisting conviction about this. In fact, none of these patients suffered from known major illness, and almost all recognized the unreasonable nature of their fear. Most of the illness phobic subjects reported that a fear response was cued by physical symptoms, although a few had no somatic symptoms. In these cases the fear itself, together with its cognitive component, was the focus of preoccupation. Most subjects reported vigilance toward bodily sensations, and many indicated that they repeatedly examined their bodies for signs of illness. The fear persisted despite reassurance, but about half felt that their concerns about illness had not been taken seriously by doctors or others. In fact, the effect of their fear upon medical care was often substantial. Out of fear, some subjects avoided going to the doctor, whereas others repeatedly sought reassurance from physicians. The demographic and illness characteristics of illness phobic and panic disorder subjects are shown in Table 2. The majority of illness phobics were men, whereas panic disorder subjects were predominantly women. The age of onset of illness phobia was similar to that of panic disorder, but the onset distribution was skewed; the median
Demographic and illness variables ror subjects with illness phobia and panic disorder
Variable Age (mean) Sex (% women) Age of onset (mean) Duration of illness (mean years) Type of onset (% sudden) Precipitating events (% present) Course (% remissions) Severity of symptoms (% severe) Secondary depression (%) Secondary alcohol abuse (%) Work impairment (%) Marital impairment (%) Social impairment (%) Neurotic traits in childhood (%) Phobias in childhood (%)
Illness Phobia n = 14
Panic Disorder n =82
P
40.6 42.9 23.3 17.6 64.3 71.4 42.9 35.7 7.1 21.4 0.0 18.2 0.0 7.1 28.6
37.9 57.3 26.2 10.7 51.9 68.3 20.7 52.4 61.0 20.7 22.2 42.6 35.4 22.2 24.7
NS NS NS NS NS NS NS 0.05 0.001 NS NS 0.05 0.01 NS NS
NOle: P values are for chi-square tests with one degree of freedom, except for comparisons of age. age of onset, and duration, which were examined using Student's I· tests. NS = nOI significant.
94
PSYCHOSOMATICS
Noyes et al.
age of onset for illness phobia was 21. Fewer illness phobic subjects reported severe symptoms, and more of these subjects had experienced remissions. Also, fewer illness phobics had experienced secondary depression. Lastly, fewer of the illness phobics reported social impairment associated with their illness than did the panic disorder subjects. Table 3 shows a comparison between normal, illness phobic, and panic disorder subjects on hypochondriacal, phobic, and anxious symptoms as measured by three self-rating inventories. Illness phobics reported more severe hypochondriacal symptoms as measured by the Whiteley Index (a subscale of the Illness Behavior Questionnaire), and blood/injury phobia symptoms, as measured by the Fear Questionnaire, than did panic disorder subjects. However, panic disorder subjects reported more severe social and agoraphobic symptoms as measured by the Fear Questionnaire, and anxiety and somatic symptoms, as assessed by the SCL-90. Also, the overall level of symptoms on the SCL-90 was higher for the panic disorder subjects than for illness phobic subjects. The mean Barsky Amplification Scale score for illness phobics was 25.9±6.7; for normal sub-
jects it was 20.5±7.3 (P = 0.06). Also, the mean Illness Concerns Scale score was 37.3±15.6 for illness phobics and 6.ltlO.0 for normal subjects (P < 0.001). Positive family histories (first-degree relatives) for anxiety disorders were found in 50.0% of illness phobics and 52.8% of panic disorder subjects. Of the illness phobics, 21.4% had a first-degree relative with illness phobia. In addition, 7.1 % of illness phobic subjects had family histories of panic disorder, compared to 41.7% of panic disorder subjects. Family histories of mood disorder were found in 35.7% and 15.3%, respectively, and family histories of alcohol abuse were found in 21.4% and 36.1 %, respectively. Illness phobic and panic disorder subjects differed little with respect to separation from a parent before age 15 (35.7% vs. 32.0%), parental overprotection (14.3% vs. 20.5%), or poor relationship with a parent (57.1% vs. 40.2%). As is shown in Table 4, illness phobic subjects rated their parents as less caring and slightly more protective than normal subjects, but none of these differences were statistically significant. In terms of personality (Table 4), the illness phobic subjects scored higher on impairment of personality functioning (impairment/distress scale of the
TABLE 3. Mean scores on the Whiteley Index. Fear Questionnaire, and Symptom ChKklist-9CJ for normal, illness phobia, and panic disorder subjKts Instrument Whiteley Index Disease phobia Disease conviction Somatic preoccupation Total Fear Questionnaire Blood/injury Agoraphobia Social phobia Total Symptom ChKklist-90 Anxiety Phobia Somatization Total
Normal n = 14
Illness Phobia n= 14
Panic Disorder n = 14
P
0.001 0.001 0.05 NS
0.4 0.2 0.3 1.4
1.9 9.8
0.9 0.6 1.5 4.4
3.6 2.2 5.0 10.8
16.2 5.8 9.3 31.3
9.6 12.7 15.8 38.1
0.02 0.05 0.05 NS
2.0 0.5 4.9 25.4
14.7 3.5 9.9 84.2
18.8 10.9 17.8 119.7
NS 0.001 0.05 0.05
3.5
1.3
NOle: P represents comparisons of illness phobia and panic disorder subjects using Student"s I-tests. NS significant.
VOLUME 33· NUMBER I • WINTER 1992
=not
95
Illness Phobia and Panic Disorder
PDQ) and reported more abnormal personality traits than the normal subjects. Twelve panic disorder subjects scored above the cutoff for one or more personality disorders, compared to eight illness phobics and six normal subjects. Five panic and illness phobic subjects and two normal subjects scored 2 or more on the illness distress scale, indicating impairment in personality functioning. DISCUSSION Our illness phobic subjects were fearful of developing specific diseases, usually some form of cancer or heart disease; thus, their fears were focused on single illnesses and not on multiple symptoms or illness in genera\.7 In addition to concern about specific illnesses, our subjects showed two other features that appeared to distinguish them from patients with hypochondriasis. Most of our patients were more distressed by fear and by anxious thoughts than they were by somatic symptoms. Physical distress was relatively minor and, in a few instances, absent, as Mayou 20 previously observed. Thus, psychological symptoms dominated the clinical picture, and patients tended to characterize their problem as one of fear or fearful thoughts. Consistent with this focus on psychological distress, our patients recognized the unreasonableness of their fear, and any real conviction about being seriously ill tended to be short-lived. They did not believe that TABLE 4.
they were ill, but, rather, they feared the future possibility. Early on, Pilowsky21 identified independent dimensions of disease phobia and disease conviction among hypochondriacal patients, which were later confirmed by Bianchi. 22 Consequently, patients can be expected to vary with respect to these features; as Table 3 shows, disease phobia scores were much higher than disease conviction scores in our illness phobic subjects. We previously observed prominent hypochondriacal or illness phobic features among patients with panic disorder,S and our observations were confirmed by Fava et a\. 9 This prompted our comparison of illness phobic and panic subjects, from which we conclude that these are separate disorders. To begin with, only two of the illness phobic subjects had ever experienced spontaneous panic attacks, and only two reported symptoms of agoraphobia. Also, examination of symptom inventory scores showed that illness phobic and panic subjects had different patterns of symptoms. Among the illness phobics, hypochondriacal symptoms predominated, whereas among the panic subjects, agoraphobic, anxiety, and somatic symptoms dominated the clinical picture. We found that the sex ratio for illness phobia favored men, as did Warwick and Marks4 in their series. This is the reverse of the usual preponderance of women with panic disorder and agoraphobia. The illness phobias we studied seemed c1ear-
Mean scores for normal, illness phobia, and panic disorder subjects on the Personality Diagnostic Questionnaire and Parental Bonding Instrument
Instrument Personality Diagnostic Questionnaire Impairment/distress Unstable cluster Anxious cluster Total
Normal n = 14
Illness Phobia n = 14
Panic Disorder n = 14
P
0.4 5.8 6.4 19.1
1.0 9.5 9.8 28.4
1.5 10.1 14.0 35.0
NS NS NS NS
28.6 10.8 26.6 8.9
23.1 11.5 21.4 13.5
22.6 18.6 17.1 12.0
NS NS NS NS
Parental Bonding Instrument Maternal care Maternal protection Paternal care Paternal protection
Note: P represents comparisons of illness phobia and normal subjects using Student's t-tests. NS = not significant.
96
PSYCHOSOMATICS
Noyes et al.
ly related to environmental precipitants. In fact, 7 of 14 subjects related the onset of their phobia to experience with illness. For four, symptoms began immediately after the development of serious illness in a family member. In addition, one woman developed symptoms after being told that she had an abnormal chest x-ray. Another, a respiratory therapist, developed a fear of throat cancer, following exposure to a patient with this disease. Still another, with an extensive smoking history, developed a fear of lung cancer. This relationship to environmental factors has been noted by previous authors. 2,J.7 However, we did not find evidence that parental attitudes had influenced the development of illness phobia. Our subjects with this disturbance did not report that their parents had been more protective than the parents of normal controls. Therefore, we were not able to confirm Bianchi's observation of greater parental overprotection among psychiatric inpatients with illness phobic features. 3 In terms of possible genetic factors, half of our subjects with illness phobia had positive family histories of anxiety disorders, including three with illness phobia and one each with panic disorder and obsessive-compulsive disorder. Thus, while exposure to illness appeared to be an important factor, inherited vulnerability also may have contributed to the development of this disorder. Based on the study of our patients and a review of previous case series, we drew up the diagnostic criteria shown in Table 5. If illness phobia is to find its way into the psychiatric TABLE S. Criteria for illness phobia developed by the authors. To meet these criteria a patient must show evidence of A through F A. An unreasonable fear that one has. or is about to develop. specific and serious illness B. Persistence of fear despite medical evidence to the contrary C. Vigilance toward. and scanning of. one's body for signs or symptoms of serious illness D. Distress caused by bodily sensations or other cues to serious illness E. Persistent avoidance of external cues to illness and/or seeking of reassurance about health status F. Recognition that one's fear is unfounded
VOLUME 33· NUMBER I • WINTER 1992
nomenclature as a subtype of hypochondriasis, then its distinguishing characteristics must be identified and its predictive validity must be established. The criteria we propose emphasize fear of specific illness, reassurance-seeking behavior, and recognition that the fear is unreasonable. They do not include preoccupation with somatic symptoms or the conviction that one is currently ill. Thus, the fear is focal rather than diffuse. Further, like most phobic patients, illness phobics recognize the unreasonableness of their fear. 7 Psychological rather than somatic symptoms predominate, and reassurance-seeking behavior is the most prominent behavioral manifestation. The picture is quite like that of other phobic disorders, except, as Marks 23 has noted, the object of the phobia is internal and therefore inescapable. The development and testing of criteria for illness phobia will require a number of studies examining the boundaries with overlapping disorders, looking for distinguishing clinical features, unique course and outcome, differing patterns of illness in the family, biological markers (where they exist), and even differences in response to treatment. Clinically it may be important to recognize patients with illness phobia because the disorder appears to be responsive to drug and behavioral treatment. Warwick and Marks4 reported that these patients receive lasting benefit from behavior therapy in the form of exposure plus response prevention. The patients in our study were treated with imipramine for 8 weeks, and all who remained on the drug for 4 weeks or more reported at least moderate improvement. 17 Patients of this kind are infrequently diagnosed despite their heavy utilization of medical care. This is because they present with somatic symptoms and because they are often reluctant to reveal their phobic concerns. Consequently, few patients with illness phobia are treated for their illness, and fewer still are referred to psychiatrists. This situation will only be corrected when more research is done to clearly establish this diagnostic entity and to make clinicians aware of its favorable response to treatment. This study was limited by the smallness of the sample and by the method of recruiting sub97
Illness Phobia and Panic Disorder
APPENDIX A.
Illness Concerns Scale
Name To what extent have you been bothered by the thoughts, feelings, or actions listed below during the past week? I. Worry about your health
2. Fear of serious illness or death 3. Thinking there might be something seriously wrong with your body 4. Thinking you should contact the doctor about how you feel 5. Having to examine your body to see if there might be something wrong 6. Feeling convinced that you are seriously ill despite evidence to the contrary 7. Finding that you think about how you feel a lot of the time 8. Having a lot of physical symptoms thaI might be due to serious illness 9. Avoiding doctors or medical care on account of fear 10. Feeling that your concern about illness may not be realistic II. Worry about changes in your body or appearance 12. Having to avoid objects or activities that might lead to illness or injury 13. Feeling upset by things you hear or read about that remind you of serious illness 14. Finding it hard to distract yourself from how you feel 15. Feeling that people are not taking your concern seriously 16. Having to avoid reminders of serious illness or death 17. Finding it hard to believe the doctor that there is nothing seriously wrong with you 18. Feeling embarrassed about your health worries
Date Not at All
A Little Bit
Somewhat
A Lot
Extremely
0 0 0
2 2 2
3 3 3
4 4 4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
0
2
3
4
jects. Because the numbers are small, it is difficult to show differences where they might exist or to have confidence in the differences observed. Also, our symptomatic volunteers may have been self-selected for certain types of symptoms and
may have been milder than the series recruited from a clinical population. However, we have demonstrated that small numbers of patients with illness phobia can be recruited from the general population and that they are available for study.
References I. Agras S. Sylvester D. Oliveau 0: The epidemiology of common fears and phobias. Compr Psychiatry 10:151156. 1969 2. Ryle JA: Nosophobia. Journal of Mental Science 94: 117.1948
98
3. Bianchi ON: Origins of disease phobia. Aust N Z J Psychiatry 5:241-257.1971 4. Warwick HMC, Marks 1M: Behavioral treatment of illness phobia and hypochondriasis: a pilot study of 17 cases. Br J Psychiatry 152:239-241, 1988
PSYCHOSOMATICS
Noyes et al.
5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition. Re· vised. Washington. DC. American Psychiatric Association. 1987 6. Kellner R: Somatization and Hypochondriasis. New York. Praeger. 1986. pp 35-38 7. Marks 1M: Fears. Phobias and Rituals. New York. Oxford University Press. 1987. pp 410-415 8. Noyes R. Reich J. Clancy J. et al: Reduction in hypochondriasis with treatment of panic disorder. Br J Psychiatry 149:631-635. 1986 9. Fava GA. Kellner R. Zielezny M. et al: Hypochondriacal fears and beliefs in agoraphobia. J Affective Disord 14:239-244. 1988 10. Spitzer RL. Williams JBW. Gibbon M. et al: Structured Clinical Interview for DSM·III-R-Patient Edition. Washington. DC. American Psychiatric Press. 1990 II. Pilowsky I, Spence ND: Manual for the Illness Behavior Questionnaire (IBQ). 2nd edition. Adelaide. South Australia. Depanment of Psychiatry. University of Adelaide. 1983 12. Derogatis LR: SCL-90: Administration. Scoring and Procedures Manual. Baltimore. MD. Clinical Psychometric Research. Johns Hopkins University School of Medicine. 1977 13. Barsky AJ. Goodson JD. Lane RS. et al: The amplifica-
VOLUME 33· NUMBER I • WINTER 1992
tion of somatic symptoms. Psychosom Med 50:51 0-519. 1988 14. Marks 1M. Mathews AM: Brief standard self-rating for phobic patients. Behav Res Ther 17:263-267. 1979 15. Hyler S. Reider R. Spitzer RL. et al: Personality Diagnostic Questionnaire (PDQ). New York. New York State Psychiatric Institute. Biometrics Research. 1983 16. Parker G. Tupling H. Brown LB: A parental bonding instrument. Br J Med Psychol52: 1-10. 1979 17. Wesner FB. Noyes R: Imipramine an effective treatment for illness phobia. J Affective Disord 22:43-48. 1991 18. Spitzer RL. Endicott J: Schedule for Affective Disorders and Schizophrenia. Lifetime Version. New York. Biometrics Research. 1975 19. Noyes R. Clancy J. Garvey MJ: Is agoraphobia a variant of panic disorder or a separate iliness? Journal ofAnxiety Disordus 1:3-13. 1987 20. Mayou R: The nature of bodily symptoms. Br J Psychi· atry 129:55-60. 1976 21. Pilowsky I: Dimensions of hypochondriasis. Br J Psychiatry 113:89-93. 1967 22. Bianchi GN: Patterns of hypochondriasis: a principal components analysis. Br J Psychiatry 122:541-548. 1973 23. Marks 1M: The classification of phobic disorders. Br J Psychiatry 116:377-386. 1970
99
