Journal of Personality Disorders, Volume 30, 1-10, 2016

© 2016 The Guilford Press

WECK ET AL.
PERSONALITY DISORDERS IN HYPOCHONDRIASIS

BRIEF REPORT

PERSONALITY DISORDERS IN
HYPOCHONDRIASIS: A COMPARISON TO PANIC
DISORDER AND HEALTHY CONTROLS
Florian Weck, PhD, Laura Carlotta Nagel, MSc,
Samantha Richtberg, PhD, and Julia M. B. Neng, PhD

Previous studies found high prevalence rates of personality disorders (PDs)

in patients with hypochondriasis; however, assessment was often based
only on questionnaires. In the current study, a sample of 68 patients with
hypochondriasis was compared to 31 patients with panic disorder and
to 94 healthy controls. Participants were investigated with the Structured
Clinical Interview for DSM-IV Personality Disorders questionnaire (SCID-
II questionnaire) and the SCID-II interview. Based on the cut-off scores of
the SCID-II questionnaire, we found a prevalence rate of 45.6% for PD in
patients with hypochondriasis. In comparison to healthy controls, patients
with hypochondriasis showed characteristics of paranoid, borderline, avoid-
ant, and dependent PDs in the dimensional assessment significantly more
often. However, no significant differences were found between the clinical
samples. Based on the SCID-II interview, only 2.9% of the patients with
hypochondriasis fulfilled the criteria for a PD. These results suggest that
PDs are not a specific characteristic of hypochondriasis.

Hypochondriasis is a chronic condition defined in the fourth edition of the

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
Psychiatric Association [APA], 2000) as the preoccupation with the fear of
having, or the idea that one has, a serious disease, for at least 6 months. In
the fifth edition of the DSM, DSM-5 [APA, 2013), the 6-month criterion also
remained for illness anxiety disorder, a diagnosis that has criteria that over-
lap with those of the former hypochondriasis diagnosis. In clinical practice,
the chronicity of hypochondriasis is obvious; patients with hypochondriasis
often suffer for more than a decade from health anxiety, which some have

From Department of Clinical Psychology and Psychotherapy, University of Potsdam, Potsdam, Germany
(F. W.); and Department of Clinical Psychology and Psychotherapy, Goethe University, Frankfurt am
Main, Germany (L. C. N., S. R., J. M. B. N.).
This research was supported by the German Research Foundation Grant WE 4654/2.
Address correspondence to Dr. Florian Weck, Department of Clinical Psychology and
Psychotherapy, University of Potsdam, Karl-Liebknecht-Str. 24-25, D-14476 Potsdam, Germany.
E-mail: fweck@uni-potsdam.de

1
2 WECK ET AL.

often had since their youth, before they seek treatment (e.g., Neng & Weck,
2015). This chronicity of hypochondriasis is one reason for the consider-
ation of close relationships between personality disorders (PDs) and hypo-
chondriasis (Hollifield, 2001). However, empirical evidence for this consid-
eration is limited, because only few studies have empirically investigated the
relationship between hypochondriasis and PDs.
Two studies used the impairment/distress subscale of the Personality Di-
agnostic Questionnaire (PDQ; Hyler et al., 1983) for the evaluation of PDs
in hypochondriasis (Barsky, Wyshak, & Klerman, 1992; Noyes et al., 1994).
In those studies, prevalence rates of PDs in patients with hypochondriasis
were 63.4% (Barsky et al., 1992) and 48.0% (Noyes et al., 1994). However,
diagnoses of PDs in those studies were based on only five items of the PDQ.
When using this method, we have no information about which PDs are the
most common in patients with hypochondriasis.
A further study overcame limitations of the described investigations and
used the Personality Diagnostic Questionnaire, DSM-IV version (PDQ-4+;
Hyler, 1994), which includes 99 true/false items to identify PDs and allows
the estimation of prevalence rates of various PDs (Sakai, Nestoriuc, Nolido,
& Barsky, 2010). The study considered a large sample of 115 patients with
hypochondriasis. According to the PDQ-4+, the prevalence rate for any PD
in patients with hypochondriasis was 76.5%. Most often diagnosed PDs
were obsessive-compulsive PD (55.7%), avoidant PD (40.9%), and para-
noid PD (36.5%). However, limitations of the Sakai and colleagues’ study
and previous studies (Barsky et al., 1992; Noyes et al., 1994) were the use of
questionnaires for the estimation of prevalence rates of PDs in patients with
hypochondriasis instead of diagnostic interviews. Therefore, prevalence rates
might be overestimated because general criteria of PDs are not verifiable
by questionnaires (see APA, 2013). Moreover, the studies lacked a clinical
control group, and it is therefore unclear whether prevalence rates of PDs
in hypochondriasis were elevated in comparison to other mental disorders.
To date, only two studies used diagnostic interviews for the evaluation
of PDs in hypochondriasis (Fallon et al., 2012; Starcevic, Kellner, Uhlenhuth,
& Pathak, 1992). Both used the Structured Clinical Interview for DSM-III-
R Personality Disorders (Spitzer, Williams, & Gibbon, 1987). The Starcevic
and colleagues’ study (1992) considered only 27 patients with hypochondri-
asis. Prevalence rate for any PD was 44.4%. Most often diagnosed PDs were
avoidant PD (33.3%), dependent PD (18.5%), and borderline PD (11.1%).
Fallon and colleagues (2012) considered 62 patients with hypochondria-
sis, 46 with obsessive-compulsive disorders, and 71 with social phobia in
their study. Prevalence rate of any PD in patients with hypochondriasis was
40.3%. Most often diagnosed PDs were paranoid PD (19.4%), avoidant PD
(17.7%), and obsessive-compulsive PD (14.5%). No significant differences
were found for the prevalence rates of PDs between patients with hypo-
chondriasis, patients with obsessive-compulsive disorders, and patients with
social phobia.
In summary, previous studies found a range of 40–77% of PDs in hypo-
chondriasis. Studies that only used self-report questionnaires generally found
higher prevalence rates for PDs (48–77%) than studies that used diagnos-
PERSONALITY DISORDERS IN HYPOCHONDRIASIS 3

tic interviews (40–44%). Previous findings are based on a few studies with
partly small sample sizes. Only two studies used diagnostic interviews, of
which one study considered relevant clinical control groups. Thus, further
research is necessary to evaluate the relevance of PDs in patients with hypo-
chondriasis.
The aim of the current study was to investigate the prevalence rates of
PDs in patients with hypochondriasis. Because of the great divergence be-
tween prevalence rates based on questionnaires and prevalence rates based
on diagnostic interviews, we considered both methods for a direct compari-
son in the current study. Moreover, we evaluated a clinical control group of
patients with panic disorder and a healthy control group. Patients with panic
disorder were considered because that disorder shows many psychopatho-
logical similarities with hypochondriasis but differs in the magnitude of
health-related anxieties and behaviors (e.g., Rief, Hiller, & Margraf, 1998;
Weck, Neng, Richtberg, & Stangier, 2012). Therefore, patients with panic
disorder are a relevant clinical comparison group for investigating specific
characteristics of patients with hypochondriasis.

METHOD
STUDY DESIGN

The institutional review board approved the study protocol, and each partic-
ipant obtained written informed consent. The study took place at the outpa-
tient unit of the Department of Clinical Psychology and Psychotherapy at the
Goethe University Frankfurt (Germany). The outpatient unit offers ambula-
tory cognitive-behavioral therapy for patients with mental disorders (about
50 therapists treating 1,200 patients). Patients with hypochondriasis were
recruited within a randomized-controlled trial, which was also conducted in
the outpatient unit (see Weck, Neng, Richtberg, Jakob, & Stangier, 2015).
Assessment took place before treatment started. Axis I disorders were
diagnosed with the Structured Clinical Interview for DSM-IV (SCID-I; First,
Spitzer, Gibbon, & Williams, 1997; German version: Wittchen, Zaudig, &
Fydrich, 1997) by trained and experienced clinicians. Inclusion criteria for
the current study were the existence of a primary diagnosis of hypochondria-
sis or panic disorder, fluency and literacy in German, and informed consent.
Exclusion criteria were a major medical illness (e.g., cancer), acute suicidal-
ity or suicidal tendencies, and the clinical diagnosis of substance addiction,
schizophrenia or schizoaffective disorder, or bipolar disorders. In addition,
we excluded patients with hypochondriasis and comorbid panic disorder as
well as patients with panic disorder and comorbid hypochondriasis.

PARTICIPANTS

Altogether, 193 participants were included in the current study. Of these, 68

had a diagnosis of hypochondriasis and 31 had a diagnosis of panic disorder.
Moreover, 94 participants without any mental disorder, according to the
SCID-I, served as a control group in the current study. Table 1 presents so-
4 WECK ET AL.

TABLE 1. Participants’ Sociodemographic Characteristics (N = 193)

Hypochondriasis Panic disorder Healthy controls
n = 68 n = 31 n = 94
Demographics
Female, n (%) 39 (57.4) 19 (61.3) 51 (54.3)
Age, Mean years (SD) 41.01 (11.96) 41.66 (15.51) 39.14 (16.64)
≥ 12 years education, n (%) 45 (72.6) 20 (66.7) 70 (76.1)
Number of disorders, n (SD) 1.54 (0.66) 1.62 (0.84) 0

ciodemographic characteristics of the participants. There were no significant

differences between the three groups regarding sex, c²(2) = 0.50; p = .78, age,
F(2, 190) = .60; p = .55, or educational level, c²(2) = 1.06; p = .59. Thirty-
one (45.6%) patients with hypochondriasis and fourteen (45.2%) with panic
disorder had an additional comorbid anxiety disorder. No significant differ-
ences were found regarding the number of disorders between patients with
hypochondriasis and patients with panic disorder, F(1, 97) = 0.20; p = .66.

MEASURES

Axis II disorders were evaluated with the Structured Clinical Interview for
DSM-IV Personality Disorders questionnaire (SCID-II questionnaire) and
the SCID-II interview (First, Gibbon, Spitzer, Williams, & Benjamin, 1997;
German version: Fydrich, Renneberg, Schmitz, & Wittchen, 1997).
The SCID-II is a questionnaire containing 119 screening questions that
utilizes a yes/no answer format. The questions correspond to the diagnostic
criteria of personality disorders described in the DSM-IV. For every PD, a
cut-off score is given, which indicates a high likelihood that the diagnostic
criteria of the indicated PD are fulfilled. Cut-off scores for the different PDs
are as follows: paranoid PD (cut-off = 4), schizotypal PD (cut-off = 5), schiz-
oid PD (cut-off = 4), histrionic PD (cut-off = 5), narcissistic PD (cut-off = 5),
borderline PD (cut-off = 5), antisocial (cut-off = 5), avoidant PD (cut-off =
4), dependent PD (cut-off = 5), and obsessive-compulsive PD (cut-off = 4).
Empirical research has found evidence that the SCID-II questionnaire alone
is a valid self-report instrument for diagnosing PDs (e.g., Bodlund, Ekselius,
& Lindstrom, 1993; Ullrich et al., 2008).
In addition to the SCID-II questionnaire, diagnostic criteria of PDs were
verified with the SCID-II interview. Experienced clinicians who were trained
in 2-day workshops (training included the implementation of the SCID-I as
well as the SCID-II) conducted the SCID-II interview. SCID-II interviews
were video recorded. We selected 14 (21%) of the patients with hypochon-
driasis randomly and had a second diagnostician make a diagnosis based
on the videotaped SCID-II interview. The agreement between diagnosticians
regarding the PD diagnoses was 100%.
PERSONALITY DISORDERS IN HYPOCHONDRIASIS 5

TABLE 2. Participants’ Means and Standard Deviations in the SCID-II Questionnaire

Hypochondria- Panic disorder Healthy con-
sis (H) (P) trols (C) ANOVA
n = 68 n = 31 n = 94
M (SD) M (SD) M (SD) F value Group differences
Cluster A Paranoid PD 1.86 (1.66) 1.83 (1.90) 1.13 (1.14) 5.78** H>C
Schizotypal PD 1.41 (1.57) 1.93 (2.30) 1.27 (1.25) 2.05 —
Schizoid PD 1.25 (1.52) 1.76 (1.77) 0.97 (1.13) 3.82* P>C
Cluster B Histrionic PD 1.43 (1.77) 1.40 (1.74) 1.67 (1.74) 0.49 —
Narcissistic PD 1.48 (1.35) 1.34 (1.29) 1.17 (1.16) 1.16 —
Borderline PD 1.67 (1.38) 1.86 (1.60) 1.07 (0.90) 7.41** H > C; P > C
Antisocial PD 0.98 (1.58) 1.79 (2.36) 1.43 (2.14) 1.95 —
Cluster C Avoidant PD 1.76 (1.61) 2.47 (2.10) 0.60 (0.91) 25.86*** H > C; P > C
Dependent PD 1.71 (1.55) 2.25 (1.78) 1.00 (1.13) 10.93*** H > C; P > C
Obsessive-compulsive PD 2.67 (1.87) 3.44 (1.67) 2.91 (1.50) 2.26 —
Note. PD = personality disorder. *p < .05. **p < .01. ***p < .001.

STATISTICAL ANALYSES

We used analyses of variance (ANOVA) to compare the mean values of the

different groups. Categorical variables (e.g., sex) were analyzed with c² tests
or Fisher’s exact tests. Post-hoc comparisons of differences between groups
were analyzed using Tukey’s post-hoc test. All reported p-values were two-
tailed, and a conventional α significance level of .05 was applied.

RESULTS
DIMENSIONAL ASSESSMENT OF PDS

We found significant group differences, F(2, 190) = 12.40, p < .001, for the
mean scores of the SCID-II questionnaire (Items 1–119). Post-hoc tests reveal
significant differences between patients with hypochondriasis and healthy
controls (p = .001), significant differences between patients with panic dis-
order and healthy controls (p < .001), but no significant differences between
patients with hypochondriasis and patients with panic disorder (p = .26).
Table 2 presents the dimensional assessment of the different PDs based
on the SCID-II questionnaire. In comparison to healthy controls, patients
with hypochondriasis had significantly higher scores for paranoid PD, bor-
derline PD, avoidant PD, and dependent PD. We did not find significant
differences between patients with hypochondriasis and patients with panic
disorder for any of the PDs.
Based on a dimensional assessment of PD clusters (Cluster A = odd dis-
orders; Cluster B = dramatic, emotional, or erratic disorders; and Cluster C =
anxious or fearful disorders), we found significant group differences only for
Cluster A, F(2, 190) = 5.44, p = .005, and Cluster C, F(2, 190) = 14.87, p <
6 WECK ET AL.

TABLE 3. Percentage of Personality Disorders According to the SCID-II Questionnaire

(Based on Cut-Offs) and the SCID-II Interview (Presented in Parentheses)
Hypochondriasis Panic disorder Healthy controls
n = 68 n = 31 n = 94
% % %
Cluster A Paranoid PD 16.2 (0) 12.9 (0) 2.1 (0)
Schizotypal PD 5.9 (0) 12.9 (0) 1.1 (0)
Schizoid PD 7.4 (0) 12.9 (0) 2.1 (0)
Cluster B Histrionic PD 7.4 (1.5) 6.5 (0) 5.3 (0)
Narcissistic PD 1.5 (0) 0 (0) 1.1 (0)
Borderline PD 2.9 (0) 3.2 (0) 0 (0)
Antisocial PD 11.8 (0) 16.1 (0) 19.1 (0)
Cluster C Avoidant PD 16.2 (1.5) 32.3 (6.5) 1.1 (0)
Dependent PD 8.8 (0) 9.7 (0) 0 (0)
Obsessive-compulsive PD 26.5 (0) 41.9 (0) 23.4 (0)
Any personality disorder 45.6 (2.9) 67.7 (6.5) 39.4 (0)
PD = personality disorder.

.001, but not for Cluster B, F(2, 190) = 0.68, p = .51. Post-hoc tests revealed
significant differences between patients with panic disorder and healthy con-
trols (p = .007) for Cluster A, but no significant differences between patients
with panic disorder and patients with hypochondriasis (p = .37) and only
a nonsignificant trend between patients with hypochondriasis and healthy
controls (p = .08). For Cluster C, we found significant differences in post-hoc
tests for all groups (ps < .02). Patients with panic disorder had the highest
scores and healthy controls the lowest. Patients with hypochondriasis took
a middle position.

CATEGORICAL ASSESSMENT OF PDS

Table 3 shows the categorical assessment of PDs based on the cut-off scores
of the SCID-II questionnaire and the SCID-II interview. In the SCID-II ques-
tionnaire, 45.6% altogether of the patients with hypochondriasis reached the
cut-off score for any PD. Patients with hypochondriasis most often reached
cut-off scores for obsessive-compulsive PD, avoidant PD, and paranoid PD.
In the SCID-II interview, only 2.9% of the patients with hypochondriasis
fulfilled the diagnosis of any PD: One patient with hypochondriasis fulfilled
the criteria of an avoidant PD and one the criteria of a histrionic PD. Based
on the SCID-II interview, we found no significant differences between pa-
tients with hypochondriasis and patients with panic disorder regarding the
prevalence of PDs (p = .59).

DISCUSSION

Based on the dimensional and the categorical assessment, prevalence rates

of PDs in hypochondriasis were not elevated in comparison to patients with
panic disorders. In comparison to healthy controls, patients with hypochon-
PERSONALITY DISORDERS IN HYPOCHONDRIASIS 7

driasis showed characteristics of paranoid PD, borderline PD, avoidant PD,

and dependent PD significantly more often in the dimensional assessment.
However, only 2.9% of the patients with hypochondriasis fulfilled the crite-
ria for any PD in the diagnostic interview.
Most of the previous studies found higher prevalence rates of PDs in
hypochondriasis than we did. One reason for this could be the different
methodological approaches. Several of the previous studies used only ques-
tionnaires for the assessment of PDs and found rates between 48 and 77%
(Barsky et al., 1992; Noyes et al., 1994; Sakai et al., 2010). We found higher
rates of PDs in patients with hypochondriasis when we used the SCID-II
questionnaire (45.6%) in comparison to the SCID-II interview (2.9%).
For the estimation of prevalence rates of PDs, results based on the SCID-
II interview seem to be more important than results based on the SCID-II
questionnaire. Based on questionnaires, it is not possible to verify whether
the “inner experiences and behaviors of an individual deviate markedly from
the expectations of the individual’s culture” (see APA, 2013). Additional
general criteria of PDs (e.g., that the behavior pattern is enduring and inflex-
ible across a broad range of personal and social situations) are not assessable
with a questionnaire. Thus, ignoring the general criteria of PDs would lead
to an overestimation of prevalence rates of PDs in hypochondriasis.
Previous studies using diagnostic interviews found prevalence rates of
40.3% (Fallon et al., 2012) and 44.4% (Starcevic et al., 1992) of any PD
in patients with hypochondriasis. Those prevalence rates are considerably
higher than the prevalence rate of 2.9% that we found in the current study.
Cross-cultural differences might be the reason for these findings. Both of the
previous studies using interviews were conducted in the United States while
the current study was conducted in Germany. Prevalence rates of PDs in the
general population were found to be lowest in Europe and highest in North
and South America (see Tyrer, Reed, & Crawford, 2015). This general find-
ing could also explain our differing results. A further relevant difference of
our study is the use of the diagnostic interview for DSM-IV, while previous
studies used the diagnostic interview for DSM-III-R.
In the direct comparison of patients with hypochondriasis and patients
with panic disorder, we found no significant differences regarding the preva-
lence of PDs in the dimensional or categorical assessment. Therefore, the
presence of PDs or characteristics of PDs does not seem to be a specific fea-
ture of patients with hypochondriasis but rather a general characteristic of
mental disorders (see Tyrer et al., 2015). The relatively low prevalence rate
of PDs in patients with hypochondriasis in our study also indicates that PDs
are not a prominent feature of hypochondriasis.
In comparison to healthy controls, patients with hypochondriasis showed
characteristics of paranoid PD, borderline PD, avoidant PD, and dependent
PD significantly more often in the dimensional assessment. The relevance of
avoidant PD for hypochondriasis was also found in previous studies (Fallon
et al., 2012; Sakai et al., 2010; Starcevic et al., 1992). However, as opposed
to previous studies (Fallon et al., 2012; Sakai et al., 2010), our study found
8 WECK ET AL.

no evidence for the relevance of obsessive-compulsive PDs in patients with

hypochondriasis. Differences to healthy controls in the dimensional assess-
ment do not seem to be specific for patients with hypochondriasis, because
patients with panic disorder show a comparable difference pattern. This
result is in accordance with the study of Fallon and colleagues, who also
found no differences regarding the prevalence rates of various clinical con-
trol groups and patients with hypochondriasis.
Limitations of our study should be considered. First, patients in our
sample all sought psychological treatment for their health anxiety. However,
patients with health anxiety often remain in medical treatment settings but
never choose psychological treatment. Therefore, our selection of patients
with hypochondriasis might not be representative. This limitation could ex-
plain the differences to the study of Starcevic and colleagues (1992), who
investigated a sample that received pharmacological treatment; however, it
does not explain the differences to the study of Sakai and colleagues (2010),
who investigated a sample that received psychotherapy as well.
Second, patients with hypochondriasis had high rates of comorbid dis-
orders. Therefore, our results could be influenced by these comorbid dis-
orders, and it can be questioned whether the findings can be transferred to
patients with hypochondriasis without comorbid disorders. However, high
rates of comorbid disorders are typical of health anxiety and hypochondria-
sis (Scarella, Laferton, Ahern, Fallon, & Barsky, 2016; Sunderland, Newby,
& Andrews, 2013), and therefore, the current sample seems representative
for patients with hypochondriasis.
Third, the current study was based on the criteria of the DSM-IV. In
DSM-5, the diagnosis of hypochondriasis was split into two diagnoses that
contain pathological health anxiety, namely somatic symptom disorder
(SSD) and illness anxiety disorder (IAD; APA, 2013). IAD should be consid-
ered when somatic symptoms are not present or only mild in intensity, and
SSD should be considered when one or more somatic symptoms are present.
Therefore, it is unclear what the prevalence rate of PDs is in the two DSM-5
diagnoses. Empirical investigations have given evidence that, in comparison
to patients with IAD, patients with SSD are more impaired and have more
comorbid disorders (Bailer et al., 2016). Therefore, we assume that preva-
lence rates of PDs are higher in SSD than in IAD. However, future studies
should empirically investigate the prevalence rates of PDs in the new DSM-5
diagnoses.
In sum, our study found no evidence for an elevated prevalence rate of
PDs in patients with hypochondriasis. In the dimensional assessment, we
found no specific characteristics of PDs in patients with hypochondriasis.
Differences to previous studies might be explained by general cross-cultural
differences. Future studies should consider this hypothesis with cross-cultur-
al investigations of patients with pathological health anxiety.
PERSONALITY DISORDERS IN HYPOCHONDRIASIS 9
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