Overlapping and Distinctive Features of Hypochondriasis and Obsessive–Compulsive Disorder

Pergamon

Journal of Anxiety Disorders, Vol. 14, No. 6, 603–614, 2000 Copyright  2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0887-6185/00 $–see front matter

PII S0887-6185(00)00053-0

Overlapping and Distinctive Features of Hypochondriasis and Obsessive–Compulsive Disorder Fugen Neziroglu, Ph.D., Dean McKay, Ph.D., and Jose A. Yaryura-Tobias, M.D. Institute for Bio-Behavioral Therapy and Research, Great Neck, New York, USA

Abstract—The spectrum of obsessive–compulsive disorders has received a great deal of theoretical attention, but there has been relatively little associated empirical research. The purpose of this study was to compare three groups of patients; those diagnosed with hypochondriasis (HC, a proposed spectrum condition), obsessive– compulsive disorder (OCD) and those with both OCD and HC (OCD/HC). The results show that patients with HC scored highest on a measure of overvalued ideas, and that the HC and HC/OCD groups scored significantly higher on measures of panic and agoraphobic cognitions. The groups also differed significantly for symptoms associated with compulsions. The patient groups were not different for measures of obsessions, depression, and anxiety. The results provide partial support for inclusion of HC in the spectrum of obsessive–compulsive disorders, but also provide indirect support for the association between HC and panic disorder. These results are interpreted in light of distinguishing characteristics among obsessive–compulsive spectrum conditions.  2000 Elsevier Science Ltd. All rights reserved. Keywords: Obsessive–compulsive disorder; Hypochondriasis; Overvalued ideas; Obsessive–compulsive spectrum disorder

The obsessive–compulsive spectrum of disorders includes a wide range of conditions, many of which have not been empirically tied to obsessive– compulsive disorder (OCD). Among the conditions that have been proposed as part of this spectrum include body dysmorphic disorder, bulimia nervosa, anorexia nervosa, trichotillomania, and even some substance abuse disorders (Hollander, 1993). Whereas there has been considerable postulation about

Portions of these data were presented at the 29th annual meeting of the Association for Advancement of Behavior Therapy, Washington, DC. Dean McKay is now at Fordham University, Department of Psychology, Bronx, New York. Requests for reprints should be sent to Fugen Neziroglu, Institute for Bio-Behavioral Therapy and Research, 935 Northern Blvd., Great Neck, NY 11021. E-mail: [email protected]

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these relations, the supporting data have primarily stemmed from similarity of treatment response to interventions used for OCD (i.e., Zohar, Kaplan, & Benjamin, 1994) and apparent overlap in phenomenology, family history, and patterns of comorbidity (Goldsmith, Shapira, Phillips, & McElroy, 1998). The persuasiveness of an argument linking these conditions to a broader spectrum of obsessive–compulsive disorders would rest upon other population similarities. For example, it has recently been shown that body dysmorphic disorder does share common features with OCD (McKay, Neziroglu, & Yaryura-Tobias, 1997). Rubinstein, Altemus, Pigott, Hess, & Murphy (1995) have found similar levels of obsessionality in a sample of bulimics. Support for inclusion in the spectrum for other conditions has been less convincing, such as in the case of trichotillomania (Himle, Bordnick, & Thyer, 1995). Hypochondriasis (HC) has also been considered a member of the spectrum of obsessive–compulsive disorders. The shared relation has been documented at phenomenological and symptom levels (Barsky, 1992). It has also been suggested that HC and OCD may be treated by using similar methods (Fallon, Klein, & Liebowitz, 1993a; Fallon, Rasmussen, & Liebowitz, 1993b; Yaryura-Tobias & Neziroglu, 1997a, 1997b). A recent study showed that OCD patients have high levels of illness-related concerns, suggesting that the base rate of hypochondriacal concerns even in patients without HC, but with OCD, is considerable (Savron et al., 1996). However, other trait similarities have not been explored, and no direct comparisons have yet been made with HC patients. It is also possible that some attributes present in more severe cases of OCD are more normative in HC. For example, one fundamental characteristic identified in HC is a strong disease conviction (Kellner, Hernandez, & Pathak, 1992). A description of disease conviction would appear similar to elevated overvalued ideation, a prognostic indicator in OCD (Kozak & Foa, 1994). In the case of HC, the essential belief is that a disease is present, and compulsions revolve around the identified illness. This is fundamentally different from OCD where compulsions are directed toward preventing an obsessional idea from becoming reality. Further, most frequently OCD patients state that both the obsessions and compulsions are senseless. Barsky (1992) details several important differences that theoretically distinguish these groups. HC patients see their fears as realistic, that a disease/illness is actually present, possess pervasive ideas of illness as part of their personality, are public about their concerns, and experience genuine somatic discomfort. These are all contrary to the typical experience and cognitive manifestations of OCD, where obsessions and fears are held secretly and are seen as unrealistic and separatefrom their personality. Indeed, the description of HC along these dimensions is similar to the higherorder personality disturbance that Eysenck (1982) suggested was part of secondary anxiety disorders (such as HC). It should be noted that the prognostic significance of overvalued ideas have been mixed, due in part to the

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absence of valid assessments of this form of psychopathology. This situation may be remedied due to the recently developed overvalued ideas scale (Neziroglu et al., 1999), a reliable and vailid measure of overvalued ideas. A more fundamental difficulty exists in the diagnosis of HC, as some have questioned its appropriateness as an Axis I condition in the Diagnostic and Statistical Manual (DSM-IV, 1994; American Psychiatric Association, 1994). The DSM-IV identifies symptoms typical of HC, with an additional specifier “with poor insight.” However, the validity of the diagnosis (from the previous edition, which was identical except for the specifier “with poor insight”) has been called into question (Noyes et al., 1993). Essentially, physicians in other medical disciplines recognize that HC exists, but rarely diagnose the condition. Noyes et al. (1993) suggest that a diagnosis is rarely made because there are no effective treatments at this time, and the ability to accurately predict the actual disorder has not been established. Assessment of poor insight has been included to accommodate those who view HC as similar to OCD (the current edition of the DSM includes this specifier for OCD, and the other spectrum disorders as well). Recent literature has suggested that OCD and its spectrum counterparts sometimes present with overvalued ideation (OVI). This has been described as an increased sense that the obsessions and associated rituals approach reasonableness (Kozak & Foa, 1994). Barsky (1992) also indicated that OVI frequently occurs in persons with HC. Although considerable weight has been given to the idea that HC is part of the spectrum of obsessive–compulsive disorders, it has likewise been suggested that HC shares common features with panic disorder (Ahmad, Wardle, & Hayward, 1992), depression (Salkovskis & Clark, 1993), and in some delusional disorders as assessed with the Positive and Negative Symptom Scale (Kay, Opler, & Lindenmayer, 1988). Of these, the link to panic disorder has received the most empirical attention. Indeed, some have suggested that excessive health-related concerns, such as HC, is an important predictor of later panic disorder (Fava, Grandi, Rafanelli, & Canestrari, 1992). Hypochondriasis has also been identified as a frequently co-occurring condition in patients with panic disorder (Bach, Nutzinger, & Hartl, 1996; Benedetti et al., 1997). Although such evidence is persuasive, recent investigations have also shown that the relationship between HC and panic is not complete, with HC being explained by other psychopathology as well (Barsky, Barnett, & Cleary, 1994). Taken together, the literature appears to support hypochondriasis as an important contributor to panic disorder, but the relation with OCD is as yet unclear. In light of the literature cited above, it appears that a direct comparison between HC and OCD would shed additional light on the similarities and differences between these conditions. Such comparisons would also assist in clarifying the extent to which HC belongs in the spectrum of obsessive–

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compulsive disorders. It was hypothesized that HC patients would exhibit similar levels of obsessionality, but show higher levels of OVI. It was also hypothesized that there would be higher levels of panic-related disturbance and depression in the HC group than in the OCD group. Included here was a group that was diagnosed with both HC and OCD to further delineate similarities and differences between the HC and OCD groups.

METHOD Participants All three groups were seen at an outpatients facility (Institute for BioBehavioral Therapy and Research) specializing in the treatment of anxiety disorders and OCD. They were referred from a variety of sources, such as psychologists and psychiatrists in the community, other patients, and advertisements in local media or by attending community self-help groups. The composition of the diagnostic groups were as follows. Obsessive-compulsive disorder sample. Twenty-two patients diagnosed with OCD participated. There were 13 males and 9 females. The mean age at the time of testing was 33.4 years (SD ⫽ 7.8). Hypochondriasis & OCD sample. Twenty-six patients with both OCD and HC (henceforth, HC/OCD) participated, of whom 4 were male and 22 female. The mean age at time of testing was 31.4 years (SD ⫽ 7.1). Hypochondriasis sample. Sixteen patients with HC participated. Here, 5 were male and 11 female. The mean age at time of testing was 38.17 (SD ⫽ 7.17). Diagnostic Criteria Diagnoses were established using the Structured Clinical Interview for DSM-III-R (SCID-P; Spitzer, Williams, Gibbon, & First, 1992). The SCID-P has been found to have adequate reliability for diagnosing the range of Axis I psychopathology listed in DSM-III-R (Segal, Hersen, & Van Hasselt, 1994). At the time the data were collected, the version for DSM-IV was not yet available. A subsample (n ⫽ 5) for each group was examined for interrater agreement by independent interviews by two raters, and acceptable values for kappa was found (␬ ⫽ .95 for HC and HC/OCD, ␬ ⫽ 1.0 for OCD). In this instance, two independent evaluators examined each patient with diagnoses compared afterward.

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Materials Body Sensations Questionnaire. The Body Sensations Questionnaire (BSQ; Chambless, Caputo, Bright, & Gallagher, 1984) is a 14-item scale assessing fear reactions associated with bodily symptoms. It has been found to have adequate reliability, and scores are typically elevated for patients with panic disorder (Chambless et al., 1984) and recent data have suggested that the BSQ uniquely explains variability in panic symptoms (Asmundson, Norton, Lanthier, & Cox, 1996). All items are rated on a five-point Likert scale ranging from 0 (not at all) to 4 (very much). Mobility Inventory. The Mobility Inventory (MI; Chambless, Caputo, Jasin, Gracely, & Williams, 1985) is composed of 26 items assessing avoidance of various places and situations, yielding two subscales. These are avoidance of places and situations alone, or when accompanied. Recent psychometric data have suggested that the subscales are reliable and valid (Arrindell, Cox, van der Ende, & Kwee, 1995). All items are assessed on a five-point Likert scale ranging from 0 (not at all) to 4 (very much). Yale-Brown Obsessive-Compulsive Scale. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989) is a 10-item clinician administered scale that assesses obsessions and compulsions, as well as forming a total score. There are five identical items for each subscale, assessing frequency, distress, social/occupational interference, resistance and control over either obsessions or compulsions. Each item is rated from 0 to 4, with higher scores indicative of greater severity of symptoms. Although factor analyses have shown that this is a two-factor scale (McKay, Danyko, Neziroglu, & Yaryura-Tobias, 1995; McKay, Neziroglu, Stevens, & Yaryura-Tobias, 1998), the total score is reported here as well for comparison to the HC group, where the properties of the Y-BOCS are yet unknown. In the administration of the Y-BOCS, no hypochondriasis symptoms were assessed as part of the interviews. That is, any obsessive–compulsive symptoms reported by the patients that were not related to significant illness concerns such as those evident in hypochondriasis were rated here. Any hypochondriasis related concerns were instead rated with a modified version of the Y-BOCS, described here. Yale-Brown Obsessive-Compulsive Scale for Hypochondriasis (Y-BOCSHC). This scale is identical in form to the original Y-BOCS except each item was tailored to address symptoms of hypochondriasis. This has been done with other obsessive–compulsive spectrum disorders such as Body Dysmorphic Disorder (Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996) and Trichotillomania (Stanley, Swann, Bowers, Davis, & Taylor, 1992). For the purposes

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of comparison, the Y-BOCSHC was scored the same as the Y-BOCS (subscales for obsessions and compulsions, and a total score). Overvalued Ideas Scale. The Overvalued Ideas Scale OVIS; Neziroglu et al., 1999) is a 10-item clinician administered scale that can assess the extent a patient holds his/her belief to be true. The impact of overvalued ideas is assessed on several different dimensions. These include belief strength, highest and lowest belief strength in past week, reasonableness of belief, accuracy of belief, extent belief is shared by others, patient attributes for others disagreeing with beliefs, effectiveness of compulsions, degree of resistance, and extent disorder is responsible for belief. All items are rated from 1 to 10, with higher scores indicative of greater overvalued ideas. Reliability is adequate, with internal consistency of .95 and a two-week test-retest reliability of .93. Convergent validity has been established with subscales of the Y-BOCS (ranging from .44 to .83) and discriminant validity has been established with measures of anxiety and depression using the Hamilton Scales (.47 and .53, respectively). In general, there appears at this point adequate convergent validity for the OVIS, whereas discriminant validity has not been as well established. The scale is structured with numerous anchor points and probe questions to aid the clinician in rating overvalued ideas. Beck Depression Inventory. The Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) was administered to assess vegetative signs and symptoms associated with depression. Composed of 21 items, it has been well established as having adequate reliability and validity. Each item is rated from 0 (neutral) to 3 (severe symptomatology). Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) was administered to assess symptoms of anxiety typically experienced by each patient group. Each item is rated in a similar fashion to the BDI, and assesses symptoms and cognitions associated with anxiety. Its reliability and validity has been found to be adequate. State-Trait Anxiety Inventory. The State-Trait Anxiety Inventory (STAI; Spielberger, 1983) is composed of two subscales (state and trait anxiety) and was administered to affirm any findings associated with the BAI and to determine the nature of long-standing anxiety symptoms of each patient group. Each scale is composed of 20 items, with items rated from 1 to 4 (1 ⫽ not at all; 4 ⫽ very much). It is a norm-referenced test, with adequate reliability and validity.

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TABLE 1 Means and Standard Deviations for Measures for All Diagnostic Groups Measure BSQ MI: alone MI: accompanied Y-BOCS: obsessions Y-BOCS: compulsions Y-BOCSHC: obsessions Y-BOCSHC: compulsions OVIS BDI BAI STAI: state STAI: trait

HC

HC/OCD

OCD

F(2,61)

45.1(5.3)a 68.1(9.6)a 45.8(9.2)a 6.8(4.8) 6.1(3.4)a 14.7(4.6) 7.2(5.6) 8.9(2.0)a 18.1(7.9) 21.9(9.1) 55.7(8.8) 59.2(8.4)

41.1(4.2)a 65.3(8.1)a 44.0(7.2)a 6.5(3.8) 10.5(3.1)b 11.0(2.0) 8.0(4.3) 5.6(0.8)b 19.0(5.7) 21.5(8.8) 56.9(6.1) 60.3(7.1)

27.3(5.8)b 34.5(7.1)b 25.4(6.8)b 12.4(5.7) 16.2(6.8)c

6.71* 7.29* 5.88* 2.18 4.94* 0.72# 0.56# 5.34* 1.23 1.01 1.12 0.99

3.8(1.3)c 26.4(5.2) 24.1(8.1) 51.3(7.4) 55.7(9.3)

Groups with different subscripts (a,b,c) are significantly different using Scheffe correction. Note. BSQ ⫽ Body Sensations Questionnaire; MI ⫽ Mobility Inventory; Y-BOCS ⫽ Yale-Brown Obsessive-Compulsive Scale; Y-BOCSHC ⫽ Yale-Brown Obsessive-Compulsive Scale for Hypochondriasis; OVIS ⫽ Overvalued Ideas Scale; BDI ⫽ Beck Depression Inventory; BAI ⫽ Beck Anxiety Inventory; STAI ⫽ State-Trait Anxiety Inventory. Values in parentheses are SD. # indicates comparisons only between HC and HC/OCD groups, df ⫽ (1,41). * p ⬍ .05.

Procedure Once diagnoses were established with the SCID-P, patients were interviewed with the Y-BOCS, Y-BOCSHC (for HC and HC/OCD), and OVIS. They were administered the self-report materials, which were completed in the office before leaving.

RESULTS The results are organized according to areas assessed, such as fear and avoidance (BSQ and MI), affective states (BDI, BAI, STAI), or features of obsessive–compulsive symptoms (Y-BOCS, Y-BOCSHC, OVIS). Where appropriate, comparisons were conducted with the HC and HC/OCD groups to the OCD group, using the Scheffe correction to control for Type I error. The data for all measures are presented in Table 1. Fear and Avoidance of Environmental and Internal Stimuli Fear of bodily symptoms, as assessed with the BSQ, revealed a significant difference between the groups (F (2,61) ⫽ 6.71, p ⬍ .05). Further, the

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comparison between the OCD group and both the HC and HC/OCD groups was significant. Patients with OCD scored significantly lower than the other two groups. Avoidance of situations associated with anxiety, as assessed with the MI, was also significantly different between groups for ratings of being alone (F (2,61) ⫽ 7.29, p ⬍ .05) and accompanied (F (2,61) ⫽ 5.88, p ⬍ .05). The same pattern of results was found here, with OCD patients scoring significantly lower, indicative of experiencing less anxiety than either the HC or HC/OCD groups. Affective States and Traits Affective states, assessed with the BDI, BAI, and STAI all reveal no differences among patient groups. In each of the scales utilized, the groups were almost completely identical (all F ⬍ 1.3). Obsessive–Compulsive Symptoms Obsessive–compulsive symptoms were assessed by the Y-BOCS for all three groups, and by the Y-BOCSHC for the HC and HC/OCD groups. There was a significant difference between the groups for the compulsions scale of the Y-BOCS (F (2,61) ⫽ 4.94, p ⬍ .05) with comparison tests showing that OCD patients scored significantly higher on this scale than either the HC/OCD group and HC groups. Further, the HC/OCD group scored significantly higher than the HC group. There was no significant difference among the groups for the obsessions scale (F (2,61) ⫽ 2.81, p ⫽ ns). Comparisons between the HC and HC/OCD groups for the Y-BOCSHC did not reveal any differences between the groups (all F (1,41) ⬍ 1.0). There were significant differences between the groups for overvalued ideas (F (2,61) ⫽ 5.34, p ⬍ .05), with HC patients scoring highest (M ⫽ 8.9), which was significantly greater than the HC/OCD group (M ⫽ 5.6), which was in turn greater than the OCD (M ⫽ 3.8) group.

DISCUSSION The aim of this study was to stimulate research on similarities and differences between HC and OCD. It has been suggested in the literature that these two conditions share common features, enough to warrant the inclusion of HC in the spectrum of obsessive–compulsive disorders. Indeed, as noted earlier, many authors have persuasively argued in favor of tailoring treatment to HC based upon existing protocols used for OCD (Fallon et al., 1993a, 1993b; Yaryura-Tobias & Neziroglu, 1997a, 1997b). However, as noted in Barsky (1992), HC has remained largely unexamined, and the extent to

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which HC is similar to, or distinct from, other psychopathological states remains unclear. It was hypothesized that HC patients would exhibit higher levels of overvalued ideas, which was supported by the data here. Indeed, it appears that those who only had OCD had the lowest overvalued ideas, with the patients presenting with both HC and OCD having a level between OCD and HC. This is noteworthy as overvalued ideas have been theoretically tied to poorer treatment outcome. Since it has been largely acknowledged that HC is a difficult condition to treat (Barsky, 1992), then this finding lends empirical credence to this claim. Although the groups were equivalent in their level of obsessionality, patients with OCD exhibited higher levels of compulsivity. This can be largely explained by the differential nature of what would constitute compulsions in hypochondriasis. Visits to the doctor or other professional may constitute rituals that occur at a very low level. Unlike traditional OCD, rituals for HC can be performed only infrequently. Instead, the obsessional quality of patients with HC is a more informative finding, where the level was at a significant level, commensurate with that observed in the OCD group. Indeed, when hypochondriacal symptoms were conceptualized as obsessive and compulsive in nature (with the Y-BOCSHC), the HC and HC/OCD groups did not differ. Differences were noted between HC and OCD patients on the BSQ and MI, instruments typically used to assess severity of panic. The HC, and to a lesser extent HC/OCD, groups evidenced significantly greater scores on these measures in relation to the OCD group. The diagnostic criteria for HC are the misinterpretation of bodily symptoms and a preoccupation with them. Therefore, it is not surprising that patients with HC endorsed more fear reactions to bodily symptoms. Physiological symptoms may represent an antecedent variable that behaviorally elicits the urge to check for illness or seek reassurance, and is accompanied by disastrous thoughts that are obsessive in quality. Indeed, this pathway resembles Barlow’s theoretical explanation of panic (Barlow, 1988) and is supportive of the link between HC and panic disorder (Ahmad et al., 1992; Salkovskis & Clark, 1993). Although the comparison was not with a panic disorder group, this would lend support to the connection HC shares with panic disorder, as noted previously (Bach et al., 1996; Benedetti et al., 1997; Barsky et al., 1994; Fava et al., 1992, 1996). A limitation of these findings is that the diagnoses were based on DSMIII-R, rather than DSM-IV criteria. However, it should be noted that the diagnostic criteria did not appreciably change from one edition of the DSM to the next. In fact, the one major elaboration for both diagnoses was the inclusion of the identifier “with poor insight” that was not present in DSMIII-R. Another limit involves the characteristics of the HC group. The patients in the HC sample here were seeking psychological treatment for

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hypochondriacal concerns. This is atypical for patients with HC, where they typically seek treatment at medical practices. Therefore, additional research is warranted to determine if these findings generalize to other medical settings. In summary, the present study provides support for inclusion of HC as a member of the spectrum of obsessive–compulsive disorders based on similarities in affective states and obsessionality. This link is not without its limitations since these data provide additional indirect support for the connection between panic and HC. Although HC patients scored significantly higher for overvalued ideas, it appears that this is a crucial variable involved in the distinction between disorders that are included in the spectrum. We have argued elsewhere that this was likewise the case for Body Dysmorphic Disorder (McKay et al., 1997). It appears that HC is also a part of the spectrum, with elevated overvalued ideas and panic-related cognitions as critical distinctive variables. An additional distinctive constellation of variables involves the degree of panic-related cognitions and associated avoidance evident in HC. Although the presence of these symptoms do not rule out the inclusion of HC in the spectrum, it does create a clinical picture that is more complicated than assumed in the model of obsessive– compulsive-related psychopathology. Further research is warranted to delineate the extent HC is similar to panic as well as OCD in order to fully appreciate the nature of this condition, and how to best structure treatment.

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