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The Boundary between Hypochondriasis, Personality Dysfunction, and Trauma

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34 Current Psychiatry Reviews, 2014, 10, 34-43

The Boundary between Hypochondriasis, Personality Dysfunction, and Trauma

Michael Hollifield1,2,* and Lisa D. Finlay1,3

1
The VA Long Beach Healthcare System, 5901 E. 7th St., Long Beach, CA 90822, USA; 2The Pacific Institute for
Research and Evaluation, 602 Encino Place NE, Albuquerque, NM 87102, USA; 3Fuller Graduate School of Psychology,
135 N. Oakland Ave., Pasadena, CA 91182, USA

Abstract: Hypochondriasis (HC) has presented physicians and researchers with nosological challenges since Freud’s era.
Part of the difficulty lays in the significant overlap between the constructs of mental illness and personality disorders that
already exists when it comes to understanding almost any psychological phenomena (i.e., state versus trait debate).
Indeed, many of the symptoms of HC are similar to those of other mental illnesses such as anxiety, yet HC has also been
associated with particular personality traits, cognitive styles, attitudes, and personality disorders. Likewise, there has been
debate as to whether HC should be considered secondary to some other disorder or as a primary diagnosis in its own right.
Finally, the etiology of HC is not well understood. Empirical literature suggests possible genetic components to HC, in
addition to several potential environmental factors. In this article we review key theoretical works and empirical studies
on the intersection of personality dysfunction and HC. In addition, we consider the role that trauma may play in the
development of HC in certain individuals. Traumatic experiences are already widely linked to somatoform disorders.
However, the characteristic features of hypochondriacal presentation (e.g., illness conviction, illness phobia, and failure to
respond to reassurance from physicians) may be related to particular types of traumatic experiences which, when they
occur in infancy and/or childhood, interfere with secure attachment and identity formation.
Keywords: Attachment, development, diagnosis, disorder, hypochondriasis, personality, somatoform, trauma.

INTRODUCTION particular, because classic descriptions of HC depict

somatization of conflict, hostility, and anger, it is curious
Hypochondriasis (HC) is associated with many
that so little is known about the role of trauma in the space
personality traits and personality disorders. However, the
between HC and personality dysfunction. Is it plausible that
extent to which HC overlaps with or is distinct from
hypochondriacs, or at least a subset of them, have a form of
personality disturbance is muddied by theoretical differences
embodied PTSD? If so, how do these patients differ from
in the way some very basic constructs of personality and
other HC patients?
mental illness are understood. In cultures that do not share
the Western presumption of the separation between body and
mind, the very criteria of HC are “senseless” [1]. But even HYPOCHONDRIASIS AS A STATE ILLNESS
within the Western medical model there remains a soft
boundary between HC and personality, and the epistemology Clinical Features and Measurement
of that confusion revolves around two central debates. First,
Pilowsky [2] identified the three dimensions of bodily
state versus trait distinctions for psychiatric diagnoses in preoccupation, disease phobia, and disease conviction that,
general are not settled and are particularly relevant to HC.
coupled with a failure to respond to reassurance, is typical
Second, the etiology, genesis, and maintenance of the disorder
in HC. This work has been replicated [3, 4]. External
escapes clear definition, in part due to the first debate. The
validity and construct stability over time have also been
gene-environment interactions that determine the risk and
demonstrated for HC [5-7]. Discriminant validity for the
expression of the illness also need further evaluation. In the
diagnosis is less sound than internal and external validity [7]
environment domain, the role of chronic stress and trauma is but new research has indicated at least some evidence for a
surprisingly underappreciated in studies of HC, especially
genetic component in HC. Of course, one major caveat to the
given the burgeoning knowledge of the role that early
validity of HC as a construct, as well as any environmental
adverse experiences play in the development of many
factors that may contribute to its development, is that it is
disorders involving the hypothalamic-pituitary-adrenal (HPA)
largely assessed by self-report, either by questionnaire or
axis. These disorders include depression, anxiety, metabolic
interview. This potential validity problem is similar to that of
syndromes, and posttraumatic stress disorder (PTSD). In personality disorders as well [8, 9], which is discussed
below.

*Address correspondence to this author at the The VA Long Beach

The handful of family and twin studies conducted on HC
Healthcare System, 5901 E. 7; Tel: 562 826-8000, Ext 5308; Fax: 562 826- have failed to yield evidence for a genetic component [10,
5969; E-mail: michael.hollifield@va.gov 11], but these studies were limited by small sample size (e.g.,

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Hypochondriasis, Personality and Trauma
<40 twin pairs). Larger twin studies on the heritability of HC
using the Minnesota Multiphasic Personality Inventory
(MMPI) Hypochondriasis (Hs) scale have found genetic
factors accounting for up to 35% of the variance in Hs scores
[12] although the MMPI Hs scale assesses awareness
of bodily sensations rather than specific hypochondriacal
features. A more promising study was conducted by Taylor
et al. [13] on a sample of 88 monozygotic and 65 dizygotic
twin pairs. They measured HC with the Illness Attitude
Scales (IAS), controlled for effects of medical morbidity to
isolate what could truly be considered excessive health
anxiety, and found heritability on the four subscales of HC:
for fears of illness, pain, and death and degree of interference
in functioning caused by bodily sensations, genetic factors
accounted for 34-37% of the variance; for treatment-seeking
and disease conviction, genetic factors accounted for 10-13%
of the variance.
Several studies have found shared genetic components
for functional somatic syndromes [14-17]. In sum, these
results support the notion that genetic factors are more easily
linked to anxiety in general than to HC specifically, that HC
is largely linked to environmental phenomena, and that
environmental influences may even be specific to the four
facets of HC [18]. As identified in other articles in this issue,
the boundaries between HC and other diagnostic entities
remains a work in progress.
Historical Categorizations
Germane to a discussion about the boundaries between
HC, personality, and trauma is the historical categorization
of HC as primary or secondary [19]. In the primary form the
conviction of an undiagnosed disease begins early in life [20]
and is not caused by another medical or psychiatric disorder.
Wollenberg [21] distinguished between “incidental” and
“constitutional” HC and considered the latter to be a form of
personality disorder. Primary HC has also been conceptualized
as a psychological process [22], a perceptual and cognitive
style [22], a style of communication and defense [23, 24],
and a personality disorder [24, 25].
In the secondary form, disease phobia and conviction are
induced by another illness, such as depression [1, 26, 27],
panic disorder with or without agoraphobia [28-31] or medical
disorders [4]. Indeed, many have observed the relationship
between HC and melancholia, depression, neurasthenia [32-
34] and anxiety [27, 31, 35, 36]. Hypochondriasis has also
been associated with paranoia [37] and other psychotic
thinking processes (e.g., delusions of physical disease)
[38-40].
The historical assumption has been that primary and not
secondary HC is associated with personality disturbance
[41]. Although the primary-secondary distinction may be
important in treatment planning [42], it does not appear to be
linked to unique personality or psychosocial variables.
Pilowsky [43] evaluated personality structure in patients with
both primary and secondary HC utilizing a clinical examination.
Men with primary HC were found to have a high prevalence
of obsessional (84%), hypochondriacal (65%), anxiety prone
(60%), and sensitive (43%) personalities. Women had high
rates of obsessional (79%), anxiety prone (79%), sensitive
Current Psychiatry Reviews, 2014, Vol. 10, No. 1 35
(51%), and hypochondriacal (41%) personalities. A combined
gender sample of secondary HC showed high rates of anxiety
prone (86%), obsessional (75%), and hypochondriacal (69%)
personalities prior to the onset of HC. More research about
the possible primary-secondary relationship to personality
traits would help to clarify the issue.
HYPOCHONDRIASIS AS A TRAIT (PERSONALITY)
Personality is often conceptualized and discussed in three
ways: 1) attitudes, 2) personality traits and dimensions, and
3) personality disorders. Attitudes are more heterogeneous
than traits and dimensions; in turn, the latter are broader than
disorders.
Attitudes
Mandeville [44] was probably the first to write about the
“attitudes” of disease phobia and disease conviction. Kellner
[45] wrote that Romberg first noted the phenomenon of
bodily preoccupation and amplification in HC in 1851when
he attributed the disorder to a “sensitivity of the nerves”.
Despite the fact that, years later, HC was defined as an Axis
I mental disorder, the three “attitudes” (disease phobia,
disease conviction and bodily preoccupation) were initially
seen as personality characteristics associated with HC as a
physical disorder.
The 20th century saw an explosion of theoretical
literature about “attitudes” in HC. The most commonly cited
are defense and conflict resolution, communication style,
hostility and anger, and a cognitive style related to a
heightened awareness of bodily sensations. Several authors
[46-48] consider HC a defense against stressful interpersonal
situations. Sullivan [48] postulated that the hypochondriacal
person was not capable of securely engaging with others
except via his bodily symptoms. Likewise, Maslow and
Mittlemann [47] wrote that the hypochondriacal person
solved interpersonal problems by increasing social
detachment and focusing on the self, using her symptoms for
social engagement, a view similarly taken by Busse [46].
Most views about HC as defense and conflict resolution
focus on bodily preoccupation and symptoms as ways to
withdraw into the self because of a sense of inadequacy in
coping with interpersonal and social situations [49, 50].
Hypochondriasis has also been considered a nonverbal
interpersonal communication style associated with the
“sick role” [22, 51]. Views about the relationship between
hostility/anger and HC, reviewed by Kellner [20], center
around the ideas that hostility and anger are either etiologic
to HC or that HC is utilized as a defense against hostility and
anger. It was speculated that the hypochondriacal person
could not or would not communicate verbally because of a
fear of hostility, a sense of inadequacy, or a need to connect
interpersonally and socially while lacking skills to do so.
Elsewhere it has been theorized that HC is associated
with abnormal self-observation [52], selective perception of
somatic sensations [23], amplification of physical sensations
[53], and a belief that the physical sensations mean that there
is an illness in one’s body [54]. Additionally, hypochondriacs
exhibit an excessive perception of bodily vulnerability, an
36 Current Psychiatry Reviews, 2014, Vol. 10, No. 1
overestimation of the likelihood of being ill and at risk of
death, and an excessive fear of death [31, 54-59].
There is substantial empirical literature about attitudes in
HC. Rief and colleagues [60] found that hypochondriacal
persons catastrophized minor bodily complaints and had a
self-concept of being weak and unable to tolerate stress.
However, some of this research is marred by the fact that
somatization was not controlled for: in some studies, patients
had lower self-esteem and were more negative in their self-
appraisal on the Attitudes Toward Self (ATS) scale [61] than
controls [62] yet others have demonstrated that the negative
self-appraisal was mostly accounted for by somatization, as
assessed by the Symptom Questionnaire [63], rather than HC
[56].
Pilowsky and Katsikitis [64] showed that HC was highly
correlated with abnormal illness behavior. Although research
infers abnormal communication in HC, studies have not
directly compared hypochondriacs with controls in their
communication style.
Finally, anger and aggression have been associated with
the tendency to somatize [65] and with disease fears [62]. An
uncontrolled study suggested that hypochondriacs harbor
anger and distrust toward other people and are likely to hold
grudges [66]. Inhibition of anger was found to be a
component of HC in another study [67]. Utilizing the IAS,
Kellner and colleagues [23] did not find a relationship
between hypochondriacal fears and hostility, yet there were
associations between somatization and hostility.
There is some evidence that aspects of the hypo-
chondriacal “attitude” are linked to perceptual or cognitive
styles that are hard-wired to some extent. For instance,
hypochondriacal persons have been found to have an
inherent supersensitivity and a lower threshold for perception
of physiological processes [4], and a tendency to amplify
physical sensations [5, 68]. Furthermore, those with high
scores on scales measuring HC were found to be more
accurate in distinguishing between two different flashes of
light in rapid succession [69], more accurate in estimating
their heart rate [70], but less accurate in perceiving somatic
sensations [71]. Moreover, subjects with higher scores report
more symptoms during pulmonary function tests [72] and
notice symptoms more often when they read about them
[54]. Hypochondriacal patients differ from normal subjects
and anxious patients in both their perception and their
misinterpretation of normal bodily sensations [73], which
may be due to affective fluctuations [71].
Personality Traits and Dimensions
Tyrer [74] noted that Kraepelin may have been the first to
write about persistent HC as a personality characteristic.
Prior to the 20th century, HC was most associated with
hysteria. Since then, it has been linked to egocentricity,
defiant pride, miserliness, reliability, conscientiousness,
obstinacy, irascibility, vindictiveness [75], orderliness and
parsimoniousness [76], neuroticism [7, 25, 56], narcissism
[77-81], avoidance, and histrionic and borderline traits [31].
The concept of neuroticism has become prominent in
theory and research about HC [6, 56, 80]. This may be partially
epiphenomenal. There are six conceptual dimensions of the
Hollifield and Finlay
neuroticism scale on the NEO Five-Factor Inventory [83]:
anxiety, hostility, depression, self-consciousness, impulsivity,
and vulnerability, most of which are independently
associated with HC. Tyrer’s description of the neurotic
syndrome, a pervasive and long-standing presentation of
anxiety and depressive features, has also been linked to
hypochondriasis [82].
In addition to obsessive traits [43, 84], narcissistic
personality traits have been closely linked with HC [77-80;
85-87]. Both classical [88, 89] and contemporary [81]
authors have hypothesized that HC is part of a defective ego
structure (possibly as a consequence of poor object
relations), and that narcissistic injury may result in a
defensive focus on the body-self. In this model, defensive
behaviors about perfect health amplify somatic perception,
cognitive distortion about the meaning of symptoms, and
fear of illness and death; subjects are prone to believe that
“inner badness” may cause the body to suddenly and perhaps
fatally betray them at any time.
The empirical literature suggests abnormal personality
development or abnormal personality traits in HC, yet many
studies do not identify characteristic traits [90]. In his
review, Kellner [4] concluded that studies varied regarding
the percentage of hypochondriacal persons with abnormal
personality traits, and that the conflicting data were largely a
function of different populations studied and methods used
to assess both HC and personality. Nevertheless, a brief
review of prominent studies is in order.
Katzenelbogen [91] reviewed charts of 26 women and 25
men from a psychiatric clinic to determine symptoms,
personality, and environmental influences in hypochondriacal
patients without other mental disorders. The most
prevalent personality features in men, of 13 listed, were
conscientiousness, rigidity, stubbornness, and being
opinionated (all 40%), seclusiveness (36%), and sensitivity
(32%). The most prevalent personality features in women, of
17 listed, were conscientiousness and sociability (both 35%),
stubbornness, and sensitivity (both 27%). Based on his work
with 225 hypochondriacal patients, Ladee [35] believed that
there was a subgroup of patients who were “constitutionally
nervous with a vegetative-dystonic substratum”. He wrote
that others had character neuroses, with subtypes of “organ
hypochondriacal development, paranoid hypochondria, the
hystero-psychopathic form acting out type, and chronic
hypochondriacal depersonalization”.
Some have tried to determine temporal relationships
between HC and personality traits. Pisztora [92] conducted
psychological testing of 135 hypochondriacal patients and
reported that, prior to the onset of HC, 59% were considered
to suffer from neuroses, 31% exhibited psychopathic and
other personalities, 25% demonstrated psychotic personalities,
16% had hypochondriacal personalities, and 16% lacked
conspicuous personality traits. Pisztora concluded that it is
the basic personality of the individual that determines how
the illness will manifest itself. Sarkisov [93] studied
personality development in 72 hypochondriacal patients
without a premorbid personality disorder. He believed there
were three stages in this development, the last of which was
characterological disturbances. These disturbances were of
three types: the hysterohypochondriacal, the obsessional
Hypochondriasis, Personality and Trauma
hypochondriacal, and the asthenohypochondriacal. Bobrov
[94] conducted structured examinations in 51 hypochondriacal
patients in whom a personality disorder had seemed to
appear prior to the onset of HC. He found a high prevalence
of psychopathic traits, inadequacy, and poor social
adaptation including diminished work performance.
Hollifield and colleagues [56] investigated the relationship
between HC and personality dimensions using the NEO
Five-Factor Inventory [83]. Subjects identified as hypo-
chondriacal using the IAS [95] were more neurotic and less
extroverted than control subjects, but did not differ from
controls in openness, conscientiousness, or agreeableness.
Analysis of variance demonstrated that the personality
variance was accounted for more by somatization than HC,
although interaction was observed between the two regarding
extroversion. Noyes and colleagues [6] also found high
levels of neuroticism in hypochondriacal persons.
Personality Disorders
Aside from HC as a personality characteristic, several
authors have considered it to be “constitutional” or a form of
personality disorder [21]. Freud [77] discussed the
psychopathology of HC in a paper on narcissism, which was
the first description of HC related to what would later be
defined as a specific personality disorder. Narcissistic traits
have been well described in association with HC, as
discussed above, but the link to narcissistic personality
disorder has received little attention.
Starcevic [84] theorized a relationship between HC and
obsessive-compulsive personality disorder, and noted four
common characteristics: 1) excessive experience of personal
vulnerability and insecurity, 2) excessive need for control, 3)
poor tolerance of uncertainty, and 4) peculiar cognitive style
with marked attention to detail, diminished ability to
withdraw attention from undesirable signals, and overall
cognitive constriction and rigidity.
As with studies on HC and personality traits, the
empirical research on the relationship between HC and
personality disorders suffer from differing populations and
methodology [4]. Some studies have found that a substantial
proportion of patients with HC do not have an established
personality disorder upon clinical assessment [35, 96].
Kellner [96] studied 36 patients with hypochondriacal
neurosis in England and found 12 had a personality disorder,
though 8 of them had no evidence of a personality disorder
before the onset of HC. Starcevic and colleagues [31]
utilized the Structured Clinical Interview for DSM-IV Axis
II Personality Disorders (SCID-II) [97] and found an
increased prevalence of avoidant, histrionic, and borderline
personality disorders in panic disorder patients with
secondary HC in comparison with panic disorder patients
without HC. However, personality disorder in general was
not associated with secondary HC in panic patients, and the
increased prevalence of the three specific personality
disorders may have been due to an association of panic
disorder itself with these types of character pathology [31,
98].
In contrast, Barsky and colleagues [99] utilized a five-
item subscale of the Personality Diagnostic Questionnaire
Current Psychiatry Reviews, 2014, Vol. 10, No. 1 37
(PDQ) [100] in an outpatient medical clinic and found that
the 42 hypochondriacal persons were more likely than the 76
non-hypochondriacal persons to have a probable personality
disorder (63% vs. 17%). Further, 19% of the hypochondriacal
persons were diagnosed with antisocial personality disorder
compared with 5.3% of the non-hypochondriacal persons.
Noyes et al. [6] also used the PDQ and found a higher
likelihood of personality pathology in hypochondriacal than
in non-hypochondriacal persons. Sakai et al. [101] examined
the prevalence of personality disorders on a sample of 115
patients meeting DSM-IV criteria for HC. Patients’ self-
report on the Personality Diagnostic Questionnaire-4+,
Hopkins Symptom Checklist-90-Revised, and the Whiteley
Index revealed that 76.5% of them had one or more
personality disorders and 44.3% had more than 3 personality
disorders. The most common was obsessive-compulsive
personality disorder (55.7%), followed by avoidant
personality disorder (40.9%).
THE PROBLEM DISTINGUISHING BETWEEN
STATE AND TRAIT
Distinctions within and between Axis I (state) disorders
and Axis II (trait) disorders are increasingly recognized as an
ontological problem. First, overlap among the 10 personality
disorders in the Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSM-IV) [102] is common, and
mixed personality disorders are the rule rather than the
exception. There is also no international consensus about the
criteria to establish a personality disorder diagnosis.
Furthermore, self-report questionnaires that assess personality
disorders are not highly valid (often due to poor reliability),
and the diagnostic performance of interviews has been
inconsistent. The psychometric properties of these instruments
are discussed elsewhere [8, 9]. Second, Axis I and Axis II
disorders are both characterized by symptoms, abnormal
behavior, and impairment, rendering high “comorbidity”
between Axis I and II disorders and poor construct validity
in general. Third, the DSM-IV criterion of “an enduring
pattern of inner experience and behavior” for a personality
disorder applies to many state psychiatric and other medical
disorders [99]. Finally, state and trait disorders almost
always, if not always, interact to affect the course and
outcome of state conditions. Illustrative of this epistemological
confusion is the argument by some to conceptualize HC as
an anxiety disorder because its symptoms overlap with panic
disorder and obsessive-compulsive disorder [103] and the
recommendation by others to consider HC as a personality
disorder in its own right because it is aligned with specific,
enduring, and pervasive personality characteristics [25]. The
principal of Occam’s razor suggests that understanding HC
as one entity or process that is influenced by various genetic
and environmental influences may be a more modest
approach.
THE ROLE OF TRAUMA IN HYPOCHONDRIASIS-
PERSONALITY DYSFUNCTION
Trauma
Trauma and chronic stress are associated with a plethora
of physiological symptoms. People with PTSD have a higher
38 Current Psychiatry Reviews, 2014, Vol. 10, No. 1
prevalence of self-reported cardiovascular [104-108], arthritic,
and autoimmune symptoms and diseases [109]. These
symptoms in PTSD parallel broad biological dysfunction in
HPA activity [110-118], autonomic nervous system (ANS)
[112, 119-121], and central nervous system (CNS) functions
[111, 122-124], all of which are likely to contribute to
inflammatory disinhibition and a low-level pro-inflammatory
state [125-128]. In fact, people with PTSD are at increased
risk over their lifespan for developing objectively assessed
cardiovascular diseases [129-131], rheumatoid arthritis,
psoriasis or other autoimmune diseases [105, 132], fibromyalgia
and irritable bowel disease [106], and diabetes mellitus
[133].
Trauma exposure alone is an independent risk factor for
symptoms, medical illness, poor health habits, and decreased
life expectancy [134-138]. In one study that combined
patient self-report with physician ratings, combat veterans
with PTSD were found to have a greater number of health
problems than veterans without PTSD [139]. Additionally,
PTSD severity was significantly related to both self-reported
and physician ratings of health [139]. It has also been
documented that pain symptoms are often localized to the
site of previous trauma in people with PTSD [140]. Thus,
traumatic exposure causes symptoms that, at least initially,
are often unexplained and may be considered by physicians
to be related to hypochondriacal fears and attitudes.
However, it is not known which patients with trauma-related
symptoms will go on to develop medical illness and which
patients will continue to have persistent symptoms in the
absence of documented physical disease.
In spite of this trauma-symptom diathesis and a number
of reports about somatoform disorders in specific traumatized
populations [141-143], there is a paucity of research about
the role of trauma in HC. Barsky and colleagues [144]
utilized the Childhood Traumatic Events Scale (CTES) [145,
146] in 60 outpatients with HC and 60 control patients from
the same clinic. Significantly more hypochondriacal patients
than control patients reported traumatic sexual contact (29%
vs. 7%), physical violence (32% vs. 7%), and major parental
upheaval before age 17 (29% vs. 9%). The hypochondriacal
patients also reported being sick more often as children
and missing school for health reasons, though they did not
differ on six other measures of childhood health. Data from a
twin study suggest that blood-injury phobia appears to
develop in response to traumatic events and some social
learning [147].
Other Environmental Stress
Several studies have found that, compared to non-HC
patients, HC patients report significantly more extreme
illness or injury in childhood [144, 148-151]. It is thought
that experiences of illness or poor health may contribute to
an overall sense of adversity in one’s early environment, and
may give rise to a heightened sense of physical vulnerability.
This health trauma extends to patients’ report of childhood
exposure to chronic physical illness in family members,
serious illness in a close friend, having a parent or family
member engaged in a hazardous occupation, and having a
parent with a drug/alcohol problem [62, 151].
Hollifield and Finlay
Stress perception may also play a role in the development
of HC. A study that compared perceived stressors between
patients with primary diagnoses of Depression, Generalized
Anxiety Disorder (GAD), and HC using the Life Events
Questionnaire (LEQ) [152, 153] found that all three groups
reported significantly higher incidence of family-related
stressors compared to controls, but only the HC patients
reported significantly higher incidence of health-related
stressors (96% vs. 29% for controls) [154]. Of course,
because almost any measure of childhood stress for HC
patients is based on their own self-report, researchers cannot
control for possible biases in memory or perception that
might exist amongst this population that would influence
what events are reported.
The Relationship of Trauma and Stress to Personality
Dysfunction
We will summarize contemporary findings that are most
relevant to the intersection of trauma, personality, and HC
because it is a broad field of inquiry. Neuroticism appears to
be the personality trait most highly associated with trauma
and PTSD [155]. High neuroticism constitutes a risk factor
for PTSD [156] and underlies other psychopathology that is
associated with PTSD, such as mood and anxiety disorders
[157]. Additionally, impulsivity and extraversion may mediate
exposure to stress and traumatic events [156, 158]. One large
study on combat veterans supported this link between
neuroticism, impulsivity, and PTSD: high neuroticism was
shared between PTSD and HC whereas extroversion was
high in PTSD but low in HC [159].
The other, perhaps most controversial personality type
related to PTSD is borderline personality disorder (BPD),
which has been implicated in HC by one study [31]. More
important to the relationship between trauma and the HC-
personality diathesis than BPD is the idea that trauma and
chronic stress disrupts attachment and ego-development
processes. In fact, leading traumatologists have recommended
reformulations of PTSD from early and chronic trauma that
include concepts of complicated or complex PTSD [160],
disorders of extreme stress not otherwise specified [161], and
a diagnosis of posttraumatic personality disorder that is
either organized or disorganized depending on the presence
or absence of disorganized attachment [162]. In these
formulations, the result of chronic stress and/or trauma lead
to more than a collection of well-bound symptoms, and
include deregulation of affect, cognition, and somatic
processes that re-structure the basic personality of the
individual. Central to these views are disruptions in
attachment during development.
Trauma, Attachment, and Hypochondriasis
Bass and Murphy [41] and Tyrer [74] have proposed
developmental perspectives for somatoform disorders to
suggest that they are more similar than dissimilar to
personality disorders. For support, Bass and Murphy note the
work of Craig and colleagues [148] who speculated that
early childhood illness and lack of parental care are two
separate factors during development that may manifest
together as somatizing disorders in adulthood. This work is
Hypochondriasis, Personality and Trauma Current Psychiatry Reviews, 2014, Vol. 10, No. 1 39

similar to the multiprocess view of Millon [163] regarding
the formation of personality disorder and provides
another important paradigm for understanding primary
hypochondriasis as a developmental disorder.
In his synthetic works, Attachment and Loss [164-166],
John Bowlby had as a premise that the attachment of infants
is based on a reciprocal bond with the principal caretaker.
Attachment behaviors are adaptive and transactional,
growing in number and scope as the child gains capacity to
venture out from the primary attachment figure to the outside
world. By developing an internal working model of social
relationships in the dialectical space between self and others,
the person develops a unique set of thoughts, memories,
beliefs, expectations, emotions, and behaviors which are
embodied as identity formation. In adolescence, the primary
attachment figures begin to recede and the larger community
gains predominance for identity formation. Secure attachment
confers confidence in self within one’s environment, and the
focus becomes competent negotiation in the social space.
Disruption of the secure attachment, on the other hand,
creates the need for continued self-focus, examination, and
uncertainty of one’s place in the world. Children who have
experienced abuse or neglect are more likely to demonstrate
insecure or, even worse, disorganized attachment patterns
into adulthood [167]. When identification of self in relation
to other is disorganized, physiology and behavior aligns
with this disarray, resulting in alternating aggression and
withdrawal, fear, demoralization, and clinical syndromes.
Theoretically, this dysregulation of physiology and the focus
on self lies at the core of the individual who displays
neuroticism, impulsivity, other personality traits such as
narcissism and the hypochondriacal cognitive style of
abnormal self-observation coupled with selective perception
of physical sensations. This leads to amplified perceptions of
body vulnerability and overestimation of the likelihood of
being ill [144].
Indeed, the empirical literature shows a relationship
between disrupted attachment and HC. In the most
comprehensive study of attachment and HC to date, Noyes
and colleagues [151] found that HC and somatic symptoms
were positively correlated with all of the prototypical
insecure attachment styles, especially the fearful style. They
reported that people with a fearful attachment style view
others as uncaring or rejecting, which would explain why so
many HC patients not only hold irrational fears about their
health, but also do not seem to be consoled by physicians’
assurances that they are not sick and frequently report
previous experience of unsatisfactory medical management
[42].
Furthermore, HC patients have reported more over-
protecting parental behaviors, which may have encouraged
sick role behavior [67, 151] but may also have undermined
their confidence in their own physical health. However, these
correlations are typically low and do not indicate whether

Feedback loop:
Reinforcement of
“sick role”

Feedback loop:
Poor tolerance for
uncertainty;
Heightened stress
perception

Feedback loop:
Heightened sense of
physical
Emotional
dysregulation

Fig. (1). Genesis of hypochondriasis and Co-morbid personality dysfunction.

40 Current Psychiatry Reviews, 2014, Vol. 10, No. 1
parental attitude was the cause or result of worry about the
child’s health. Moreover, the relationship between parental
style and HC has been inconsistent. Some studies revealed
correlations between HC and lack of maternal care
with paternal overprotection [62, 151, 168] whereas others
have found a relationship between HC and maternal
overprotection only [169]. Somatization patients have
reported inadequate or inattentive parenting [41, 148].
A stronger relationship has been established between HC
and report of separation anxiety in childhood. This may
relate to findings on a correlation between HC patients and
higher parental alcohol/drug problems [151]. Additionally, a
cognition identified by Freeston et al. [170] as common
amongst HC patients, that anything less than complete
certainty is extremely anxiety-provoking, is indicative of
insecure attachment.
TOWARD A SYNTHETIC VIEW OF HYPOCHON-
DRIASIS AND PERSONALITY
Given the sum of the findings, a parsimonious model of
the HC – personality diathesis rather than a “trait or state”
view is needed. As depicted in the figure, HC, like most
illness, develops in a prone individual when environmental
stress activates the process. Insecure or disorganized early
attachment may be a major factor in what makes individuals
prone to HC. Age of onset and severity of HC are thus
dependent on both the degree of proneness and the severity
and timing of stressors. For those highly prone, the only
stress needed to activate the syndrome is perceptual. The
prone person may exhibit inherent attitudes, such as
sensitivity, difficulty with interpersonal communication, self-
focus, and expression via somatic idioms. With sufficient
stress, the developing hypochondriac fears for his safety and
defends the threat to self by deeper body-focus, and in so
doing reinforces inherent attitudes which begin to appear as
neurotic, obsessional, histrionic, and avoidant traits. Akin to
the psychological narcissist who defends her fear of
defectiveness by overzealous protestations of goodness, the
hypochondriac at this stage repels the thought of a defective
body-self with defensive behaviors about perfect health.
Further stress in the context of these traits fully manifest HC
which, with its peculiar traits, also often appears as
diagnostic level personality disorder. Thus, the HC and
personality continuum share variables that both confer
proneness and worsen with environmental stress.
CONCLUSIONS
While there is a significant body of literature about the
relationship between HC and personality dysfunction,
definitive information is lacking. This gap in knowledge
exists because assessment of both HC and personality are
imprecise, the definition of terms and methodology has
varied between studies, and accounting for the variance of
co-morbidity, such as somatization, is not always complete.
The HC-personality boundary is further blurred by the
unsettled distinction between primary and secondary HC and
whether either type is more strongly associated with
personality dysfunction. The sum of evidence suggests that
HC fits within a biopsychosocial model that includes genetic
Hollifield and Finlay
predispositions, personality features, and environmental
stressors. In particular, we posit that trauma and stress are
significant contributors to the manifestation of HC, with
early trauma and neglect and subsequent attachment
difficulties interacting to predict early onset HC. This
contrasts with the view that primary HC is best thought of as
a personality disorder rather than a secondary response to
stress. Further study about the role of trauma, neglect, and
genetic/biological factors responsible for the interface
between HC and personality dysfunction as a single entity
will well serve those who suffer from it.
CONFLICT OF INTEREST
The author(s) confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENTS
Declared none.
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Accepted: June 20, 2013