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Psychosomatic Medicine 65:292-300 (2003)
© 2003 American Psychosomatic Society

ORIGINAL ARTICLES

Test of an Interpersonal Model of Hypochondriasis

Russell Noyes, Jr., MD, Scott P. Stuart, MD, Douglas R. Langbehn, MD, PhD, Rachel L. Happel, BSN, Susan L. Longley, PhD, Barbara A. Muller, MD and Steven J. Yagla, MA

From the Departments of Biostatistics (D.R.L.), Internal Medicine (B.A.M.), and Psychiatry (R.N., S.P.S., D.R.L.), University of Iowa Colleges of Medicine and Public Health, Iowa City, Iowa, and the Institute of Health, Health Care Policy and Aging Research (S.L.L.), Rutgers University, New Brunswick, New Jersey.

Address correspondence to: Dr. Russell Noyes, Jr., Psychiatry Research, Medical Education Bldg., Iowa City, IA 52242-1000. Email: russell-noyes{at}uiowa.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: The aim of this study was to test the interpersonal model of hypochondriasis proposed by Stuart and Noyes. According to this model, hypochondriasis is associated with insecure attachment that in adults gives rise to abnormal care-seeking behavior. Such behavior is associated with interpersonal difficulties and strained patient-physician relationships.

METHODS: One hundred sixty-two patients attending a general medicine clinic were interviewed and asked to complete self-report measures. Instruments included the Whiteley Index of Hypochondriasis, Somatic Symptom Inventory, Relationship Scales Questionnaire, Inventory of Interpersonal Problems, NEO Five-Factor Index, and measures of physician-patient interaction. The Structured Diagnostic Interview for DSM-III-R Hypochondriasis was also administered.

RESULTS: Hypochondriacal and somatic symptoms were positively correlated with all of the insecure attachment styles, especially the fearful style. These same symptoms were positively correlated with self-reported interpersonal problems and negatively correlated with patient ratings of satisfaction with, and reassurance from, medical care. Hypochondriacal and somatic symptoms were also positively correlated with neuroticism.

CONCLUSIONS: The findings indicate that hypochondriacal patients are insecurely attached and have interpersonal problems that extend to and include the patient-physician relationship. These data support the proposed interpersonal model of hypochondriasis.

Key Words: attachment style, • hypochondriasis, • interpersonal model, • patient-physician relationship, • interpersonal problems, • reassurance.

Abbreviations: HAQ = Health Anxiety Questionnaire.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Hypochondriasis is a preoccupation with fears of having, or the idea that one has, serious disease in the absence of physical findings. It has been variously conceptualized as a perceptual, cognitive, or interpersonal disturbance (1). According to the interpersonal model, hypochondriasis is viewed as a form of care-eliciting behavior that finds expression in physical complaints. Through unexplained somatic symptoms, patients with this disorder seek emotional and interpersonal support from family members and physicians. Need for such support, according to Stuart and Noyes (2), arises from anxious and insecure attachment that has its origin in early relations with caregivers. Lack of parental care and/or adverse early environment may cause a child to view others as unreliable in providing care. Experiences of illness or injury may heighten fear of separation and reinforce reassurance-seeking behavior. As an adult, the still insecurely attached person may communicate his or her need for care through illness behavior (3).

Unfortunately this indirect and persistent communication of attachment needs often elicits rejecting responses from others, further escalating the hypochondriacal patient’s maladaptive interpersonal behavior. Faced with persistent unexplained complaints, others—especially physicians—may question the legitimacy of the patient’s physical symptoms (4). Often medical providers focus exclusively on physical complaints, so the underlying attachment needs go unrecognized and unmet. Thus, instead of obtaining reassurance, the patient ultimately receives confirmation of the inability or unwillingness of caregivers to provide the sought-after care (5).

Support for such a model may be found in the literature on somatization, some of which deals with hypochondriasis (6–9) . Both adverse early events and negative parental attitudes have been reported by hypochondriacal adults. Studies by Barsky et al. (10) and Furer et al. (11) found more physical and sexual abuse among subjects with DSM hypochondriasis than among control subjects. They and others also elicited reports of more childhood illness among somatizing and hypochondriacal patients (10–13) . Several authors obtained retrospective reports of parental overprotection and encouragement of sick role behavior from patients with hypochondriasis (14–17) , whereas others reported inadequate or inattentive parenting (18). Based on their study of somatizers in primary care, Craig et al. (13) concluded that somatization is best modeled by a combination of inadequate parental care and childhood illness. According to them, "Childhood illness afforded an escape from neglect and abuse, or encouraged some badly needed attention from a withdrawn or indifferent parent, and thus set in motion a pattern of care-eliciting behavior that was to be repeated later in life."

Further support for the proposed model comes from evidence of interpersonal difficulties among adults with somatization and hypochondriasis, although research in this area is limited. For example, somatization and hypochondriasis have been linked to personality disturbances (19–21) . Studies of personality dimensions have consistently found positive correlations between both neuroticism (22, 23) and negative affectivity (24) and hypochondriasis. In a review of personality traits associated with adult somatization, Kirmayer et al. (20) noted that various abnormal traits have been described but that few systematic studies have been conducted. Personality disturbance may also contribute to conflict with family members and physicians (25). In fact, somatizing patients have been described as having an abrasive personality style (26, 27) .

Our aim in this study was to test the interpersonal model of hypochondriasis described by Stuart and Noyes (2). This model posits that patients with hypochondriasis have anxious and insecure attachment styles that lead to indirect and maladaptive communication of their attachment needs. We therefore hypothesized that hypochondriasis in adults is associated with the fearful style of attachment described by Griffin and Bartholomew (28). We also hypothesized that this attachment style would be evident in self-reports of interpersonal problems and unsatisfactory relationships with physicians.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Patients attending the General Medicine Clinic of the University of Iowa Hospitals and Clinics took part in this investigation. A total of 1612 patients had scheduled appointments on days when screening took place. Of these, 408 failed to appear, 220 were excluded because they were more than 65 years old, 235 were excluded because of serious mental or physical illness (eg, chronic schizophrenia, advanced cancer) or other reasons (eg, could not speak English), and 215 refused to participate. The remaining 534 completed the Health Anxiety Questionnaire (HAQ) used for screening.

When patients arrived for their appointments, they were given a brief description of the study and asked to complete the screening instrument. Those outside the age range of 18 to 65 years and those with severe physical or mental illness were excluded, as were those unable to complete the form. Patients who completed the questionnaire were contacted by telephone within 1 week and asked to participate in a brief interview. To increase statistical power, a sampling formula that called for enrolling all subjects on the ends of the HAQ distribution and a smaller proportion of those in the middle was adopted. According to this formula, 170 patients who had completed screening questionnaires were not contacted. Of the remainder, 162 participated in the study, 149 could not be reached within the specified interval, and 53 declined. The final participants represented a sequential sample.

Telephone interviews were completed by a research nurse (R.L.H.) with training and experience in psychiatric interviewing. She administered the Structured Diagnostic Interview for DSM-IIII-R Hypochondriasis and asked subjects to complete and return the remaining measures that she mailed to them.

Instruments
Hypochondriasis.
Screening was accomplished using the HAQ (29). This instrument is a 21-item measure developed to identify individuals with high levels of hypochondriacal concern. Responses are obtained on four-point Likert scales (0 = not at all or rarely to 3 = most of the time). The HAQ has good short-term test-retest reliability and appropriate discriminant validity (29). A distribution of scores for an outpatient population was available from the authors; this was an important consideration in selecting the instrument. In this study, the measure was strongly correlated with the Whiteley Index (r = 0.72).

Hypochondriacal symptoms were assessed by means of the Whiteley Index (30, 31) . This measure consists of 14 items covering hypochondriacal attitudes and concerns. Responses are obtained on five-point linear scales (1 = not at all to 5 = extremely). The items belonging to this scale form a single factor that has shown good internal consistency (32). Test-retest reliability and both discriminant and convergent validity have been demonstrated (33).

Somatic symptoms associated with hypochondriasis were assessed with the Somatic Symptom Inventory (34). This measure consists of 26 items that make up the Minnesota Multiphasic Personality Inventory hypochondriasis scale and the Hopkins Symptom Checklist somatization scale. Responses are obtained on five-point scales (1 = not at all to 5 = extremely). Among medical outpatients, scores on this instrument have been correlated (r = 0.52) with those of the Whiteley Index (34). In this study, these measures were also strongly correlated (r = 0.65).

Diagnostic criteria for hypochondriasis were assessed by means of the Structured Diagnostic Interview for DSM-III Hypochondriasis. This interview was developed by Barsky et al. (34) and follows the format of the Structured Clinical Interview for DSM-III-R (35, 36) . It has good interrater reliability and both convergent and predictive validity (34, 37) .

Adult personality.
The NEO Five-Factor Inventory was used to assess personality (38). This is a 60-item version of the NEO Personality Inventory. Items are rated on five-point bidirectional scales (strongly agree to strongly disagree). Responses are summed to yield scores for five basic dimensions: neuroticism, extraversion, openness, agreeableness, and conscientiousness. The NEO Personality Inventory, from which this instrument was derived, has shown acceptable internal consistency and test-retest reliability (38). The dimensions measured correspond to the five-factor model of personality. These have been consistently demonstrated and externally validated in various populations.

Attachment style.
Attachment style was assessed with the Relationship Scales Questionnaire (39). This is a 30-item scale that yields scores for four prototypical styles—secure, preoccupied, dismissing, and fearful—that correspond to the self/other matrix described by Griffin and Bartholomew (28). Items are scored on five-point Likert scales (not at all like me to very much like me). The subscales have shown moderate consistency. They have also shown convergent and discriminant validity with other self-report measures and interview ratings (39).

Interpersonal difficulties.
Interpersonal difficulties were assessed using the Inventory of Interpersonal Problems (40). The 64-item version yields eight subscales: domineering/controlling, vindictive/self-centered, cold/distant, socially inhibited, nonassertive, overly accommodating, self-sacrificing, and intrusive/needy. These domains of interpersonal problems have been defined, according to theory, as particular combinations of the basic dimensions of affiliation and dominance. The instrument and its subscales have good internal consistency and test-retest reliability. Convergent validity of the measure has also been demonstrated (41).

Healthcare satisfaction.
Satisfaction with health care was assessed with the Consumer Satisfaction Survey, second edition, developed by Group Health Association of America, Inc. (42). An abbreviated version contains 14 items calling for ratings on five-point linear scales (excellent to poor). Subscales examine technical quality, communication, interpersonal care, and outcome. The instrument has shown good internal consistency and reliability. It also has good content and predictive validity (42). Ten additional items were used to obtain ratings of recent health care. These included, "How worried have you been about your health?" and "How much have doctors been able to reassure you about your health?" Each was rated on a scale from 0 (not at all) to 4 (extremely or completely).

Analyses
Relationships between hypochondriasis and other continuous variables were examined by means of Pearson correlation coefficients. Because age was negatively correlated with hypochondriasis, partial correlations controlling for age were used. We also adjusted for oversampling of subjects with low and high HAQ scores so that estimates would apply to the entire clinic population. To accomplish this, we used weighted linear models (43). The observed weights were derived by first obtaining smoothed estimates of the HAQ score distribution for both the observed sample and the entire clinic population (44, 45) . The assigned weights were then obtained by taking ratios of these smoothed density estimates for each HAQ score. (A few HAQ scores were not observed in the sample, and corresponding regions of the estimated population density were redistributed over the six nearest scores. A simple triangle function was used to give greatest redistributed weight to the closest scores.)

Similar linear models with categorical variables treated as predictors were used to examine relationships between mean hypochondriasis scores and categorical variables. We also used these models to test differences in continuous measures (eg, age) between patients who met DSM-III-R criteria for hypochondriasis and those who did not. Because gender was not related to hypochondriasis in this sample, this variable was not controlled for in these analyses.

Estimates of correlations between measures of hypochondriasis and continuous variables for the entire population of general medicine patients (N = 534) were made using HAQ scores for all patients.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
One hundred seventeen women (72.2%) and 45 men (27.8%) participated in this study. Mean age was 51.0 ± 12.2 years. Nearly half (47.8%) were married. Equal percentages (35.4%) were employed and unable to work for health reasons. One hundred fifty-five patients were white, five were black, and two were Hispanic. More than half (62.9%) were receiving public funding for their medical care (federal, state, or county). Forty-nine patients met DSM-III-R criteria for hypochondriasis, and 113 did not. Those with hypochondriasis were younger (mean age, 47.6 ± 13.0 vs. 52.7 ± 11.6, p = .014), but they did not differ significantly with respect to gender or other demographic variables. The above figures apply to 162 interviewed patients, not the overall clinic population. Self-rated measures were not returned by 7 patients, so subsequent analyses are based on 155.

Table 1 shows correlations between the four adult attachment styles assessed by the Relationship Scales Questionnaire and both hypochondriacal and somatic symptoms. Negative correlations were observed with secure attachment, but positive correlations were seen with the three insecure attachment styles. The correlation with the fearful style was the strongest. Table 1 also shows relationships with three Relationship Scales Questionnaire dimensions derived by factor analysis (46, 47) . Desire for closeness and faith in others’ dependability were negatively correlated with hypochondriacal symptoms, and interpersonal anxiety was positively correlated with the same symptoms. Correlations between Relationship Scales Questionnaire scores and somatic symptoms were similar but of lesser magnitude. When the partial correlations with attachment styles were adjusted (by regression) for the influence of the others, correlations with the fearful style remained strongest.


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  		TABLE 1. Correlations Between Adult Attachment Styles and Measures of Hypochondriasisa
 
Table 2 shows correlations between interpersonal problems, as assessed by the Inventory of Interpersonal Problems, and both hypochondriacal and somatic symptoms. Modest positive correlations were observed between all eight subscales and the total score. Correlations between Inventory of Interpersonal Problems scores and somatic symptoms were similar but again of lesser magnitude.


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  		TABLE 2. Correlations Between Interpersonal Problems and Measures of Hypochondriasisa
 
Table 3 shows correlations between measures of patient-physician interaction and both hypochondriacal and somatic symptoms. The negative correlations shown indicate that hypochondriacal symptoms were associated with less favorable patient-physician relationships and less satisfaction with care. Correlations between hypochondriacal symptoms and both reassurance and satisfaction were modest, and those between somatic symptoms and these measures were significant but for the most part low.


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  		TABLE 3. Correlations Between Patient-Physician Relationship and Measures of Hypochondriasisa
 
Table 4 shows correlations between personality dimensions, assessed by the NEO Five-Factor Inventory, and both the Whiteley Index and Somatic Symptom Inventory. As may be seen, strong positive correlations with neuroticism and modest negative correlations with extraversion were observed with both symptom measures. When the partial correlations with personality dimensions were adjusted (by regression) for the influence of the other dimensions, correlations with neuroticism remained strong.


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  		TABLE 4. Correlations Between Personality Dimensions and Measures of Hypochondriasisa
 
Table 5 shows correlations between attachment styles, as assessed by the Relationship Scales Questionnaire, and interpersonal problems, as measured by the Inventory of Interpersonal Problems. In examining the correlations, we sought to learn whether attachment styles in this patient population were associated with interpersonal problems and, if so, what types of problems might be related to particular styles. Table 5 shows partial Pearson correlations adjusted for age and weighted to reflect the entire clinic population. Ratings of secure attachment were negatively correlated with interpersonal problems, whereas preoccupied and fearful attachment styles were positively correlated. Dismissing style was not significantly correlated with any self-reported interpersonal problems. The interpersonal problem subscales most highly correlated with preoccupied style were nonassertive, overly accommodating, self-sacrificing, and intrusive/needy. Those most highly correlated with fearful attachment style were vindictive/self-centered, cold/distant, and socially inhibited.


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  		TABLE 5. Correlations Between Various Interpersonal Problems and Attachment Styles
 
To learn what relationships there might be between attachment styles and patient-physician relationships, we examined correlations between our measures of both. Here we observed relatively low correlations between ratings of attachment and patient-physician interaction. Secure attachment style was positively correlated with healthcare satisfaction (r = 0.22, p = .006), but the preoccupied and fearful styles were not (r = 0.00, p = .98 and r = -0.16, p = .056, respectively). The secure and fearful, but not the preoccupied, attachment styles were correlated with reassurance obtained from physicians (r = 0.20, p = .014; r = -0.19, p = .018; and r = 0.07, p = .378, respectively).

We also examined relationships between our measures of attachment styles and personality dimensions to learn whether these were relatively independent or overlapping. Here we observed strong correlations between ratings of secure and fearful attachment and both neuroticism and extraversion. Partial weighted correlations were as follows: secure attachment was negatively correlated with neuroticism (r = -0.49, p < .001) and positively correlated with extraversion (r = 0.38, p < .0001); preoccupied attachment was positively correlated with neuroticism (r = 0.28, p = .0005) and extraversion (r = 0.20, p = .015); dismissing style was not correlated with neuroticism (r = -.03, p = .748) but was negatively correlated with extraversion (r = -0.18, p = .023); and fearful style was positively correlated with neuroticism (r = 0.47, p < 0001) and negatively correlated with extraversion (r = -0.44, p < 0001).

Given the overlap in attachment styles and personality dimensions just described, we conducted a multivariate regression analysis to determine which measures were most predictive of Whiteley Index and Somatic Symptom Inventory scores. Table 6 shows the results of this analysis. Neuroticism and dismissing style were the strongest predictors of hypochondriasis; neuroticism and fearful style were the strongest predictors of somatic symptoms. The other variables had little additional influence once these predictors were taken into account. For the Whiteley Index, the partial adjusted R2 (explained variance) for all variables except age was 0.39. For the Somatic Symptom Inventory, the partial adjusted R2 for all variables except age was 0.19.


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  		TABLE 6. Predictors of Hypochondriasis and Somatic Symptoms When Controlled for Simultaneously by Means of Multiple Regression
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We observed strong relationships between attachment styles and hypochondriacal symptoms among our medicine clinic patients. As hypothesized, we found positive correlations between the insecure styles and hypochondriacal and somatic symptoms as measured by the Whiteley Index and Somatic Symptom Inventory. Both scales were most highly correlated with the fearful style. Persons with this style have negative expectations of both themselves and others (48). They view themselves as unworthy of care and look on others as uncaring or rejecting. Their insecurity leads them to seek care, but fearing this will not be adequate, they intensify their search for reassurance. In response to their persistent complaints, caregivers often become exhausted and ultimately reject the fearfully attached patient (49). Patients of this kind may wish physicians would respond in a reliable and effective manner, but because of repeated rejection, have little faith in their ability or desire to do so (50). The result may be help-seeking behavior accompanied by anger and criticism of the care received. Such attitudes are reflected in the negative correlations between hypochondriasis and satisfaction with medical care that we observed.

According to interpersonal theory, insecure attachment is manifested in maladaptive interpersonal behavior (49, 51, 52) . Such behavior results in specific interpersonal problems, and these problems contribute, in turn, to further insecurity and an escalation of care-seeking. Our findings indicate that hypochondriasis is indeed associated with interpersonal problems. Tables 2 and 5 point to problems classically associated with fearful attachment that are also recognizable in hypochondriacal patients (53, 54) . For instance, both fearfully attached and hypochondriacal persons tend to be introverted, emotionally distant, and self-sacrificing, but at the same time needy (21, 55–57) . High correlations with emotionally distant interpersonal problems likely reflect preoccupation with somatic symptoms and demands for care associated with them (20). Table 7 shows the kind of individual problems associated with hypochondriacal symptoms.


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  		TABLE 7. Inventory of Interpersonal Problems Items Most Strongly Correlated With the Whiteley Index of Hypochondriasis
 
We sought evidence of interpersonal difficulty within the patient-physician relationship. Here we observed correlations between hypochondriasis and perceived physician characteristics as well as satisfaction with care that were in the expected (ie, negative) direction. These findings are consistent with earlier reports of low satisfaction despite high utilization of care among hypochondriacal patients (37). Also, by its very definition, hypochondriasis involves a failure of reassurance, a key feature of the patient-physician relationship (58, 59) . Consequently the observed negative correlations between hypochondriasis and physician caring and reassurance were expected. These correlations were modest but did not take into account the quantity and quality of care delivered, actual physician characteristics, and other factors that may have influenced ratings. Nevertheless such findings provide further evidence of interpersonal difficulties among patients with hypochondriasis. Consistent with our proposed model, hypochondriacal patients persist in their efforts to obtain care despite their belief that sufficient care will not be provided (5).

Because hypochondriasis is strongly linked to neuroticism, we included a measure of this and other personality dimensions in this study (21–23) . As expected, we observed a strong correlation between hypochondriasis and neuroticism. We observed equally strong positive correlations between this dimension and both the preoccupied and fearful attachment styles. In fact, when personality dimensions and attachment styles were included in a regression analysis, neuroticism remained the strongest predictor of hypochondriasis. Griffin and Bartholomew (28) previously showed significant associations between attachment styles and personality dimensions. These results do not lessen support for the interpersonal model but show that the measures of fearful and preoccupied attachment used in this study overlap with neuroticism. Yet the fact that our measure of neuroticism is a stronger predictor does not necessarily mean that the underlying dimension of neuroticism is more important than the elements that make up the interpersonal model. The finding may simply reflect the success with which different instruments measure the underlying constructs. We should also mention that neuroticism is itself associated with interpersonal difficulties (60, 61) .

Our findings may have been influenced by coexisting psychiatric symptoms or comorbidity. Among medical outpatients, strong positive correlations between depressive (r = 0.58), anxiety (r = 0.55), and somatic symptoms (r = 0.52) and hypochondriacal concerns have been observed (62). Also, rates of psychiatric comorbidity are high among general medical patients diagnosed with hypochondriasis (63). We did not assess such comorbidity in our subjects and for this reason cannot judge the extent to which observed relationships may have reflected coexisting depression, anxiety, and somatoform disorders. Future studies should examine the influences of such potential confounds.

In general we found a pattern of correlations between key interpersonal variables and somatic symptoms similar to that between those same variables and hypochondriasis. Of course, bodily symptoms are included in the DSM-IV definition of this disorder, and the Somatic Symptom Inventory has frequently been used to measure the somatic symptoms of hypochondriacal patients (34, 37) . Even so, we chose to separate somatic symptoms in our analysis. At the least such symptoms may represent a distinct dimension of hypochondriasis; at the most they may represent a more general tendency to report somatic symptoms. The correlations were generally weaker but in the same direction. They may have been influenced to some extent by physical disease and by other somatoform disorders (eg, somatization disorder, pain disorder), but they seem to support findings for hypochondriasis using the Whiteley Index.

This is a preliminary study, and a number of limitations should be noted. Our results may have been influenced by treatment-seeking and/or referral biases and, as such, may not generalize to the community. They may also have been influenced by selection bias. Some patients were unavailable or chose not to participate, and their responses might have differed from those who took part. To diagnose DSM hypochondriasis, we administered an established structured interview by telephone. Although this procedure has been used in previous studies, its reliability remains untested and may have resulted in a rate of hypochondriasis that was somewhat higher than the 4% to 9% range reported in previous studies. Also, our study relied on a self-report measure of attachment style. Observer-rated instruments are available and are considered by some the standard for this kind of assessment (64). Also, some of the observed correlations may have reflected general distress not specific to measures used in this study.

Although our findings support the interpersonal model of hypochondriasis, they raise a number of questions for future investigation. One has to do with the specificity of attachment styles across diagnostic categories. Although attachment insecurity has been linked to adult psychopathology, further efforts to relate certain styles to particular disorders are needed (65). For example, can individuals with hypochondriasis be distinguished on the basis of attachment from those with somatization disorder? Studies investigating such differences should be based on structured diagnostic interviews and should include assessment of axis I and II comorbidity. Beyond this, investigation of hereditary and early environmental factors associated with attachment difficulties in persons who develop hypochondriasis would be valuable (66). Of the various adverse early events and circumstances linked to insecure attachment, experience with illness may be a specific antecedent of this disorder (10). Whether such factors are causally related to adult psychopathology must ultimately be determined by longitudinal studies (65). As part of this study, we examined potential childhood antecedents of hypochondriasis and found some support for the hypothesis that such factors are associated with the adult disorder (67). Beyond that, however, our findings, because of their cross-sectional nature, do not tell us much about what is cause and what is effect. It is possible that hypochondriasis leads to attachment and interpersonal problems rather than vice versa.

Our findings suggest that psychological therapies specifically directed toward attachment problems may prove beneficial for hypochondriacal patients. Interpersonal psychotherapy has been used clinically to treat patients with somatizing disorders and seems to offer promise as a structured intervention (68). Rather than addressing maladaptive attachment styles directly, interpersonal psychotherapy focuses on helping patients communicate their needs for emotional support in a direct manner so that others may respond more productively. The authors have found this approach useful in a small series of cases and plan further trials.

Received for publication November 19, 2001.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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