Hypochondriasis with Panic Attacks M.D. SILVANA GRANDI. M.D. FRANCESCO M. SAVIOTII. M.D. SANDRA CONTI. M.D. GIOVANNI
n
A.
ecently, the relationship of phobic behavior Rto panic attacks has been the object of considerable debate. In DSM-III the presence of panic attacks in the setting of agoraphobia is said to indicate the severity ofthe illness. In DSM-IIIR there was a conceptual shift to the primacy of panic attacks in the production of agoraphobic symptoms. I Panic attacks, if the criteria for severity and unexpectedness are met, should be subsumed under the rubric of panic disorder. The presence of agoraphobia may be recorded as ancillary symptomatology. Similarly, if panic attacks occur during somatization disorder or major depression, a dual diagnosis is required. I The aim of this article is to describe six cases in which a dual diagnosis of panic disorder and hypochondriasis, according to DSM-III-R,I was made. All patients had been referred to the Affective Disorders Program of the University of Bologna. Diagnoses were established by the independent consensus of a psychiatrist and a psychologist using the Schedule for Affective Disorders and Schizophrenia. 2 After the initial diagnostic evaluations, a semistructured interview for eliciting prodromal symptoms of panic attacks was held. The interview, described in detail elsewhere,) is a modified version of Paykel's Clinical Interview for Depression,4 and it was performed by a clinical psychologist.
Case Reports Case l. Mrs. A. was a 52-year-old housewife with a long-standing history of hypochondriasis and disVOLUME 31, NUMBER 3· SUMMER 1990
FAVA,
ease phobia, characterized by intense "doctor-shopping" throughout Italy and frequent calls to her family physician. One year prior to evaluation, while watching a medical program on television, she suddenly became convinced that she was suffering from the disease described in the program, and she had her first panic attack. Soon other recurrent unexpected attacks followed, panicularly in the selling of intense disease conviction. Her calls to the family physician became daily, and the trips to doctors out of town more frequent. Treatment with alprazolam (0.5 mg three times a day) successfully controlled panic. but it left the hypochondriasis unchanged. Case 2. Ms. B. was a 21-year-old hairstylist with a three-year history of hypochondriasis and cancer phobia. When she was 18, she developed cancer phobia and was intensively preoccupied with it for about 18 months. Three months before evaluation, she developed AIDS phobia, thanatophobia, and panic attacks. Treatment with alprazolam (0.5 mg four times a day) resulted in fewer panic attacks, but it did not affect her hypochondriacal fears and beliefs. Case 3. Mr. C. was a 50-year-old university employee. At the age of 35, he lost his father to cancer of the stomach. Two years later, his six-year-old son underwent surgery for a benign lung tumor. One year prior to evaluation, the patient underwent nephrectomy for a benign kidney tumor (he had lost an Received February 14, 1989; revised June 28. 1989; accepted July 20, 1989. From the Affective Disorders Program, Depanment of Psychology. University of Bologna, Italy, and the Psychiatric Clinic, University of Brescia, Italy. Address reprint requests to Dr. Fava. Dipartimento di Psicologia, Universitil di Bologna-Viale Berti Pichat, 5. 1-40 I27 Bologna, Italy Copyright © 1990 The Academy of Psychosomatic Medicine.
351
Case Reports
uncle twenty years earlier to renal carcinoma). Despite an excellent outcome of surgery, Mr. C. developed bodily preoccupations and intense thanatophobia. He became very concerned about his neck lymph nodes, which he interpreted as a sign of metastasis. Six months after surgery, the patient developed panic attacks. These did not affect his daily life. However, he did increase his visits to physicians. His first panic attack took place while feeling a change in one of his neck lymph nodes. Case 4, Mrs. D. was a 39-year-old business secretary, with a 16-year history of hypochondriasis. Three years before evaluation, the patient developed pelvic pain and became convinced of a connection between regular bowel habits and well-being. The patient reponed that the lack of a morning bowel movement almost ineluctably caused a panic attack during the day, and this was confirmed by her husband. The panic attacks could strike in the most diverse times and situations. Treatment with clomipramine (75 mg per day) interrupted panic attacks but did not stop her bodily preoccupations. Nor did it decrease her visits to physicians. Case 5. Mrs. E. was a 50-year-old blue-collar worker with a 35-year history of disease phobia (consistently focused on the hem) and hypochondriasis. Eight months prior to assessment, the patient's sister, to whom she felt very close, had surgery for gastric carcinoma. Shonly afterwards, Mrs. E.'s preoccupations with having a hean attack increased, and panic attacks ensued. The patient also developed intense thanatophobia. Case 6, Mr. F. was an l8-year-old student with a three-year history of hypochondriasis and thanatophobia. When he was 17, after an inconsequential car accident, the patient's hypochondriacal fears increased, as did his beliefs associated with thanatophobia. After a few months, he developed panic attacks. He described his first panic attack as a feeling of numbness in his legs, followed by a conviction of impending paralysis.
Discussion In a paper written in 1941, Palmer described the clinical presence of panic attacks in anxiety states, phobic-obsessional disorders, alcoholism, hysteria, cardiac neurosis, menopausal states. and psychosis. and he discussed them as a mani352
festation of a general hypochondriacal syndrome. Recent research. despite DSM-III-R claims of specificity for panic attacks.· has substantiated Palmer's observations. Panic attacks have been reported in phobic patients of any kind. 6 in patients who experience major depression 7 and in patients afflicted with personality disorders. s Hypochondriasis in panic disorder has been described as a phenomenon secondary to panic attacks. 9 . lo Its secondary characteristics have been confinned by its response to treatment directed to panic attacks 9 or to the underlying agoraphobia. 1O The reverse. however. also may take place; panic attacks may result from hypochondriasis. s The six cases described here exemplify such a phenomenon. All patients met DSM-III-R criteria for both panic disorder and hypochondriasis. Agoraphobia. however. could be excluded while hypochondriasis antedated the onset of panic attacks by years. Treatment with alprazolam (Cases I and 2) or clomipramine (Case 4) controlled or decreased the intensity of the panic attacks. yet it did not relieve the hypochondriacal fears and beliefs. as it did with secondary hypochondriasis. 9 The panic attacks appeared to occur in a "crescendo" of such fears. at a time when a phobic quality in hypochondriacal anxiety prevailed. Both thanatophobia (the conviction of impending death. soon combined with a fear of any event or of any news suggestive of death. such as funerals and obituary notices") and disease phobia (a persistent. unfounded fear that one is suffering from a disease. despite repeated medical examinations and reassurance from doctors '2 ) characterized the hypochondriacal behavior of the patients here described. As Kellner remarked. in most hypochondriacal patients. panic attacks "appear to be the result of a vicious cycle of somatic symptoms and frightening thoughts. followed by more physical symptoms that in tum induce more anxiety"· I (p. 48). The phenomenology of hypochondriasis with panic attacks in the patients described in this study seems to counter the primacy and distinct quality of panic disorder as it is defined in DSMIII-R. A double diagnosis of panic disorder and hypochondriasis in these patients clearly would PSYCHOSOMATICS
Case Reports
be misleading in that it would fail to acknowledge the secondary characteristics of panic attacks. Palmer wrote that "it cannot be too much emphasized how important it is to consider the setting of these attacks, once familiarity has been acquired in recognizing the patient's history oftheir occurrence. This importance is because of the line of treatment which has to be adopted"5 (p. 210). Phenomenological methods seem to indicate that a primary/secondary distinction is feasible when panic attacks and hypochondriasis overlap.
Similarly, Coryell et aI.' showed that family study data make a primary/secondary distinction feasible when depression and panic coexist. The results of the present study should alert the clinician to inquire about hypochondriacal fears and beliefs in the presence of panic attacks, particularly when agoraphobia can be excluded.
The Affective Disorders Pro8ram is supported in part by a grant from the Ministero della Pubblica Istruzione (Rome, Italy). Ms. Luisella Pezzoli provided secretarial assistance.
References I. American Psychiatric Association: Dia!inostic andStatis· tical Manual of Mental Disorders, 3rd Edition, Rel'ised. Washington, DC. American Psychiatric Associalion, 1987 2. Endicoll J. Spilzer RL: A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 35:837-844,1978 3. Fava GA, Grandi S. Canestrari R: Prodromal symptoms in panic disorder wilh agoraphobia. Am J Psychiatry 14:1564-1567,1988 4. Paykel ES: The clinical interview for depression. J Affectil'e Disord 9:85-96. 1985 5. Palmer HA: A psychobiological approach to Ihe acute anxiety allack. Journal of Mental Science 57:208-229. 1941 6. Marks I: Agoraphobia. panic disorder and related conditions in the DSM·III·R and ICD·IO. Journal of Psycho-
VOLUME 31· NUMBER 3· SUMMER 1990
pharmacolo!iY 1:6·12.1987 7. Coryell W, Endicoll J. Andreasen NC. et al: Depression and panic attacks. Am J Psychiatry 145:293-300. 1988 8. Weiler MA. Val ER. Gaviria M. et al: Panic disorder in borderline personality disorder. Psychiatr J Un ii' Ollawa 13:140-143,1988 9. Noyes R. Reich J, Clancy J. et al: Reduction in hypochondriasis with trealment of panic disorder. Br J Psychiatry 149:631"'()35.1986 10. Fava GA, Kellner R, Zielezny M. et al: Hypochondriacal fears and beliefs in agordphobia. J Affective Disord 14:239-244,1988 II. Kellner R: Somati:ation and Hypochondriasis. New York. Praeger. 1986 12. Bianchi GN: Origins of disease phobia. Aust N Z J Psychiatry5:241-257.1971
353
n
A.
ecently, the relationship of phobic behavior Rto panic attacks has been the object of considerable debate. In DSM-III the presence of panic attacks in the setting of agoraphobia is said to indicate the severity ofthe illness. In DSM-IIIR there was a conceptual shift to the primacy of panic attacks in the production of agoraphobic symptoms. I Panic attacks, if the criteria for severity and unexpectedness are met, should be subsumed under the rubric of panic disorder. The presence of agoraphobia may be recorded as ancillary symptomatology. Similarly, if panic attacks occur during somatization disorder or major depression, a dual diagnosis is required. I The aim of this article is to describe six cases in which a dual diagnosis of panic disorder and hypochondriasis, according to DSM-III-R,I was made. All patients had been referred to the Affective Disorders Program of the University of Bologna. Diagnoses were established by the independent consensus of a psychiatrist and a psychologist using the Schedule for Affective Disorders and Schizophrenia. 2 After the initial diagnostic evaluations, a semistructured interview for eliciting prodromal symptoms of panic attacks was held. The interview, described in detail elsewhere,) is a modified version of Paykel's Clinical Interview for Depression,4 and it was performed by a clinical psychologist.
Case Reports Case l. Mrs. A. was a 52-year-old housewife with a long-standing history of hypochondriasis and disVOLUME 31, NUMBER 3· SUMMER 1990
FAVA,
ease phobia, characterized by intense "doctor-shopping" throughout Italy and frequent calls to her family physician. One year prior to evaluation, while watching a medical program on television, she suddenly became convinced that she was suffering from the disease described in the program, and she had her first panic attack. Soon other recurrent unexpected attacks followed, panicularly in the selling of intense disease conviction. Her calls to the family physician became daily, and the trips to doctors out of town more frequent. Treatment with alprazolam (0.5 mg three times a day) successfully controlled panic. but it left the hypochondriasis unchanged. Case 2. Ms. B. was a 21-year-old hairstylist with a three-year history of hypochondriasis and cancer phobia. When she was 18, she developed cancer phobia and was intensively preoccupied with it for about 18 months. Three months before evaluation, she developed AIDS phobia, thanatophobia, and panic attacks. Treatment with alprazolam (0.5 mg four times a day) resulted in fewer panic attacks, but it did not affect her hypochondriacal fears and beliefs. Case 3. Mr. C. was a 50-year-old university employee. At the age of 35, he lost his father to cancer of the stomach. Two years later, his six-year-old son underwent surgery for a benign lung tumor. One year prior to evaluation, the patient underwent nephrectomy for a benign kidney tumor (he had lost an Received February 14, 1989; revised June 28. 1989; accepted July 20, 1989. From the Affective Disorders Program, Depanment of Psychology. University of Bologna, Italy, and the Psychiatric Clinic, University of Brescia, Italy. Address reprint requests to Dr. Fava. Dipartimento di Psicologia, Universitil di Bologna-Viale Berti Pichat, 5. 1-40 I27 Bologna, Italy Copyright © 1990 The Academy of Psychosomatic Medicine.
351
Case Reports
uncle twenty years earlier to renal carcinoma). Despite an excellent outcome of surgery, Mr. C. developed bodily preoccupations and intense thanatophobia. He became very concerned about his neck lymph nodes, which he interpreted as a sign of metastasis. Six months after surgery, the patient developed panic attacks. These did not affect his daily life. However, he did increase his visits to physicians. His first panic attack took place while feeling a change in one of his neck lymph nodes. Case 4, Mrs. D. was a 39-year-old business secretary, with a 16-year history of hypochondriasis. Three years before evaluation, the patient developed pelvic pain and became convinced of a connection between regular bowel habits and well-being. The patient reponed that the lack of a morning bowel movement almost ineluctably caused a panic attack during the day, and this was confirmed by her husband. The panic attacks could strike in the most diverse times and situations. Treatment with clomipramine (75 mg per day) interrupted panic attacks but did not stop her bodily preoccupations. Nor did it decrease her visits to physicians. Case 5. Mrs. E. was a 50-year-old blue-collar worker with a 35-year history of disease phobia (consistently focused on the hem) and hypochondriasis. Eight months prior to assessment, the patient's sister, to whom she felt very close, had surgery for gastric carcinoma. Shonly afterwards, Mrs. E.'s preoccupations with having a hean attack increased, and panic attacks ensued. The patient also developed intense thanatophobia. Case 6, Mr. F. was an l8-year-old student with a three-year history of hypochondriasis and thanatophobia. When he was 17, after an inconsequential car accident, the patient's hypochondriacal fears increased, as did his beliefs associated with thanatophobia. After a few months, he developed panic attacks. He described his first panic attack as a feeling of numbness in his legs, followed by a conviction of impending paralysis.
Discussion In a paper written in 1941, Palmer described the clinical presence of panic attacks in anxiety states, phobic-obsessional disorders, alcoholism, hysteria, cardiac neurosis, menopausal states. and psychosis. and he discussed them as a mani352
festation of a general hypochondriacal syndrome. Recent research. despite DSM-III-R claims of specificity for panic attacks.· has substantiated Palmer's observations. Panic attacks have been reported in phobic patients of any kind. 6 in patients who experience major depression 7 and in patients afflicted with personality disorders. s Hypochondriasis in panic disorder has been described as a phenomenon secondary to panic attacks. 9 . lo Its secondary characteristics have been confinned by its response to treatment directed to panic attacks 9 or to the underlying agoraphobia. 1O The reverse. however. also may take place; panic attacks may result from hypochondriasis. s The six cases described here exemplify such a phenomenon. All patients met DSM-III-R criteria for both panic disorder and hypochondriasis. Agoraphobia. however. could be excluded while hypochondriasis antedated the onset of panic attacks by years. Treatment with alprazolam (Cases I and 2) or clomipramine (Case 4) controlled or decreased the intensity of the panic attacks. yet it did not relieve the hypochondriacal fears and beliefs. as it did with secondary hypochondriasis. 9 The panic attacks appeared to occur in a "crescendo" of such fears. at a time when a phobic quality in hypochondriacal anxiety prevailed. Both thanatophobia (the conviction of impending death. soon combined with a fear of any event or of any news suggestive of death. such as funerals and obituary notices") and disease phobia (a persistent. unfounded fear that one is suffering from a disease. despite repeated medical examinations and reassurance from doctors '2 ) characterized the hypochondriacal behavior of the patients here described. As Kellner remarked. in most hypochondriacal patients. panic attacks "appear to be the result of a vicious cycle of somatic symptoms and frightening thoughts. followed by more physical symptoms that in tum induce more anxiety"· I (p. 48). The phenomenology of hypochondriasis with panic attacks in the patients described in this study seems to counter the primacy and distinct quality of panic disorder as it is defined in DSMIII-R. A double diagnosis of panic disorder and hypochondriasis in these patients clearly would PSYCHOSOMATICS
Case Reports
be misleading in that it would fail to acknowledge the secondary characteristics of panic attacks. Palmer wrote that "it cannot be too much emphasized how important it is to consider the setting of these attacks, once familiarity has been acquired in recognizing the patient's history oftheir occurrence. This importance is because of the line of treatment which has to be adopted"5 (p. 210). Phenomenological methods seem to indicate that a primary/secondary distinction is feasible when panic attacks and hypochondriasis overlap.
Similarly, Coryell et aI.' showed that family study data make a primary/secondary distinction feasible when depression and panic coexist. The results of the present study should alert the clinician to inquire about hypochondriacal fears and beliefs in the presence of panic attacks, particularly when agoraphobia can be excluded.
The Affective Disorders Pro8ram is supported in part by a grant from the Ministero della Pubblica Istruzione (Rome, Italy). Ms. Luisella Pezzoli provided secretarial assistance.
References I. American Psychiatric Association: Dia!inostic andStatis· tical Manual of Mental Disorders, 3rd Edition, Rel'ised. Washington, DC. American Psychiatric Associalion, 1987 2. Endicoll J. Spilzer RL: A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 35:837-844,1978 3. Fava GA, Grandi S. Canestrari R: Prodromal symptoms in panic disorder wilh agoraphobia. Am J Psychiatry 14:1564-1567,1988 4. Paykel ES: The clinical interview for depression. J Affectil'e Disord 9:85-96. 1985 5. Palmer HA: A psychobiological approach to Ihe acute anxiety allack. Journal of Mental Science 57:208-229. 1941 6. Marks I: Agoraphobia. panic disorder and related conditions in the DSM·III·R and ICD·IO. Journal of Psycho-
VOLUME 31· NUMBER 3· SUMMER 1990
pharmacolo!iY 1:6·12.1987 7. Coryell W, Endicoll J. Andreasen NC. et al: Depression and panic attacks. Am J Psychiatry 145:293-300. 1988 8. Weiler MA. Val ER. Gaviria M. et al: Panic disorder in borderline personality disorder. Psychiatr J Un ii' Ollawa 13:140-143,1988 9. Noyes R. Reich J, Clancy J. et al: Reduction in hypochondriasis with trealment of panic disorder. Br J Psychiatry 149:631"'()35.1986 10. Fava GA, Kellner R, Zielezny M. et al: Hypochondriacal fears and beliefs in agordphobia. J Affective Disord 14:239-244,1988 II. Kellner R: Somati:ation and Hypochondriasis. New York. Praeger. 1986 12. Bianchi GN: Origins of disease phobia. Aust N Z J Psychiatry5:241-257.1971
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