Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization

The aim of this study was to investigate the internal and external validity of the Whiteley Index as a screening instrument for somatization illness. A 14-item version of the Whiteley Index for hypochondriacal traits was given to 99 of 191 consecutive primary care patients, aged 18-65 years, and to 100 consecutive patients, aged 18-60 years, admitted for the first time to a neurological ward. The primary care sample was, in addition, interviewed by means of the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) psychiatric interview. The GPs and the neurologists were asked to rate various characteristics of the patients that might indicate somatization. The internal validity of the Whiteley Index was tested by means of latent structure analysis. On this basis, a reduced seven-item scale (Whiteley-7 scale) and two subscales (i.e., an Illness Conviction and Illness Worrying scale, each with three items) were constructed. All three had a high internal validity fitting into the very restricted Rasch statistical model (p>0.05) and an acceptable transferability between most of the subpopulations investigated. In the primary care population, the Whiteley-7 and the Illness Conviction scales at cut-point 0/1 showed 1.00 and 0.87 sensitivity and 0.65 and 0.87 specificity, respectively, using as "gold standard" the fulfillment of criteria for at least one ICD-10 somatoform disorder, and 0.71 and 0.63 sensitivity and 0.62 and 0.87 specificity, respectively, as gold standard for the fulfillment of criteria for at least one DSM-IV somatoform disorder, excluding the NOS diagnostic group. The Illness Worrying subscale showed less impressive performance in this respect. The agreement between the Whiteley-7 scale including the two subscales and neurologists' rating and the GPs' rating and the somatization subscale on the SCL-90 was modest or worse. It may be concluded that the Whiteley-7 scale and the Illness Conviction subscale had acceptable psychometric profiles, and both seem to be promising screening tools for not only hypochondriasis but also for somatoform disorders in general.     

Correlates of illness worry in chronic fatigue syndrome

BACKGROUND: Anxiety about illness leading to restriction of activity and physical deconditioning has been hypothesized to contribute to the chronicity of fatigue. Pathological symptom attributions, personality traits, and depression have all been hypothesized to contribute to illness worry. METHODS: We compared 45 chronic fatigue syndrome (CFS) and 40 multiple sclerosis (MS) outpatients using a battery of psychometric instruments comprising the 12-item Illness Worry scale, the Symptom Interpretation Questionnaire (SIQ), the NEO Five-Factor Inventory (NEO-FFI), and a modified version of the SCL-90R Depression scale. RESULTS: There was no difference between the two diagnostic groups on neuroticism, depressive symptoms, as well as the three scales of the SIQ. On the illness worry index, the CFS group had significantly higher scores than the MS group. This difference was due to items tapping vulnerability to illness and the perception that others are not taking their illness seriously. Somatic attributional style, neuroticism, depressive symptoms, and age were all significant predictors of illness worry in both CFS and MS patients. CONCLUSIONS: Somatic attributions, neuroticism, and depression all contribute to illness worry in chronic illness. However, these factors do not account for the higher levels of illness worry in CFS as opposed to MS, which may be due to other specific cognitive and social interactional processes.     

Burden and coping strategies in mothers of patients with schizophrenia in Japan

Aim:  The present study was conducted to identify factors contributing to burden of care in 57 mothers caring for patients with schizophrenia.
Methods:  Members of the Federation of Families of People with Mental Illness in Nagasaki Prefecture were evaluated using well-validated scales to evaluate burden of care (eight-item short version of the Japanese version of the Zarit Caregiver Burden Interview), general health status (General Health Questionnaire 12-item version), difficulty in life, coping strategies, emotional support, and understanding of mental illness and disorders.
Results:  Burden of care was significantly associated with general health status and difficulty in life.
Conclusion:  On multiple regression it was found that 'social interests' and 'resignation', both of which are the subscales of coping strategies, exerted significant and independent effects with respect to burden of care.     

Differentiating hypochondriasis from panic disorder

Hypochondriasis and panic disorder are both characterized by prevalent health anxieties and illness beliefs. Therefore, the question as to whether they represent distinct nosological entities has been raised. This study examines how clinical characteristics can be used to differentiate both disorders, taking the possibility of mixed symptomatologies (comorbidity) into account. We compared 46 patients with hypochondriasis, 45 with panic disorder, and 21 with comorbid hypochondriasis plus panic disorder. While panic patients had more comorbidity with agoraphobia, hypochondriasis was more closely associated with somatization. Patients with panic disorder were less pathological than hypochondriacal patients on all subscales of the Whiteley Index (WI) and the Illness Attitude Scales (IAS) except for illness behavior. These differences were independent of somatization. Patients with hypochondriasis plus panic had higher levels of anxiety, more somatization, more general psychopathology and a trend towards increased health care utilization. Clinicians were able to distinguish between patient groups based upon the tendency of hypochondriacal patients to demand unnecessary medical treatments. These results confirm that hypochondriasis and panic disorder are distinguishable clinical conditions, characterized by generally more psychopathology and distress in hypochondriasis.     

Worry and use of coping strategies among older and younger adults

Eighty four adults over age 64 were compared with 110 college students on two measures of worry and on their methods of coping with worry. Results indicated that there were no differences in overall worry between the two groups, as measured by the Worry Scale for Older Adults--Revised, but on the individual subscales of health, family concerns, and world issues older adults expressed significantly more worries than younger adults. On the Penn State Worry Questionnaire, which measures a general, trait-like tendency to worry, younger adults reported significantly more worry than did the older adults. Younger adults also utilized a greater number of coping strategies in an effort to control worry. These results support the notion that older adults report relatively low levels of worrying when compared with the younger population. Explanations for these differences are discussed along with implications for the function of worry across the life span.     

Hypochondriacal traits in medical inpatients

Hypochondriacal traits were examined in 100 general medical inpatients, and correlates of these traits were examined from four perspectives: (1) emotional distress; (2) affective inhibition; (3) learned social behavior; and (4) symptom misinterpretation. In contrast to previous studies of hypochondriasis in general medical populations, this study examined patients' illness perceptions and presentation in relationship to objective health status as assessed by their treating physicians. Data concerning the illness being treated and associated illness behavior were obtained from patients and their treating physicians. Results suggested that hypochondriacal traits of "disease phobia," disease conviction, bodily preoccupation, perceptions that one's illness is more severe than the physician's assessment, and illness presentation disproportionate to demonstrable organic disease were quite prevalent. On multiple regression analyses, correlates pertaining to emotional distress appear to be preeminent in the prediction of hypochondriacal traits. However, variables pertaining to learned social behavior also provided further understanding of hypochondriacal traits in medical inpatients beyond that explained by emotional distress.     

The Cognitive Avoidance Questionnaire: validation of the English translation

This study investigated the psychometric properties of the Cognitive Avoidance Questionnaire (CAQ; Gosselin, P., Langlois, F., Freeston, M. H., Ladouceur, R., Dugas, M. J., & Pelletier, O. (2002). Le Questionnaire d'évitement cognitif (QEC): Développement et validation auprès d'adultes et d'adolescents [The Cognitive Avoidance Questionnaire (CAQ): Development and validation among adult and adolescent samples]. Journal de Thérapie Comportementale et Cognitive, 12, 24-37) English translation. Questionnaires were administered to a sample of 456 (65.3% female; mean age=23.13 years, S.D.=5.18 years) undergraduate students at Concordia University in Montreal, Canada. The CAQ assesses five worry-related cognitive avoidance strategies, namely Thought Suppression, Thought Substitution, Distraction, Avoidance of Threatening Stimuli, and the Transformation of Images into Thoughts. The CAQ scale and subscales showed good to excellent internal consistency and good stability over a 5-week period. A confirmatory factor analysis found support for the proposed subscales, though the overall goodness-of-fit was lower than expected. Preliminary evidence of convergent and divergent validity was found with measures of worry, thought suppression, and dispositional coping styles. The relationship between the CAQ and specific dispositional coping styles, however, was dependent on the context of the situation in which the information-seeking and information-avoidant coping strategies were employed. Specifically, the CAQ was negatively correlated with vigilance in controllable situations and positively correlated with both information-avoidance in controllable situations and information-seeking in uncontrollable situations.     

Illness attitudes and coping process in subjects with panic attacks.

Personality disorders may affect comorbidity and health care utilization in subjects with panic attacks. The purpose of this study was to identify differences in illness attitudes and behaviors, and in coping strategies in community-based subjects with panic attacks compared with controls. A community-based sample of 97 subjects meeting DSM-III-R criteria and matched controls completed the Illness Behavior Questionnaire, the Illness Attitude Scale, and the Ways of Coping Checklist. The panic group reported less healthy attitudes and behaviors. Although there were no panic-control differences in use of positive coping strategies, the panic group reported more use of negative coping strategies. The differences in illness attitudes and behaviors, and in coping strategies, may explain comorbidity and care-seeking behavior in subjects with panic attacks.     

The Clinical Applicability of the Self-Appraisal of Illness Questionnaire (SAIQ) to Chronic Schizophrenic Patients in Taiwan

Over the last decade, several self-report instruments to assess insight of illness from schizophrenic patients’ perspectives have been administered. The main purpose of this study was to ascertain the reliability and validity of the Taiwanese version of the Self-Appraisal of Illness Questionnaire (SAIQ) in a chronic schizophrenic sample in Taiwan. This scale is a self-administered instrument designed to evaluate attitudes toward mental illness among patients receiving treatment. In the current cross-sectional study, 104 patients who met DSM-IV criteria for schizophrenic disorders were recruited and independently interviewed. The psychometric properties of the translated SAIQ were determined, including internal consistency, test–retest reliability, and construct validity. In addition, we analyzed psychosocial and clinical characteristics as correlates of the Taiwanese version of the SAIQ. Overall, the Taiwanese version of the SAIQ was found to be internally consistent and reliable over time. This translated scale comprised a three-factor solution with factors corresponding to worry, the need for treatment, and presence/outcome subscales. The results also indicated that the three subscales and its total score were significantly associated with both the research-rated insight scale and psychopathology and mood state. This culture-specific study shows that the Taiwanese version of the SAIQ is a simple and reliable scale for use.     

Life events and hypochondriacal concerns

In a study of 165 employees of a retail firm, life events were associated with several hypochondriacal concerns and with most of the self-rating distress scales. Life events related to illness and death were associated with fear of disease and showed weak associations with somatic symptoms and anxiety. Life events unrelated to illness and death were associated with hypochondriacal beliefs, bodily preoccupations, fear of death, and most of the distress scales. Illness and death do not appear to be common recent precipitants of hypochondriacal concerns in a normal population. One of the reasons for the observed associations appears to be that preoccupation with illness and death can occur at times of distress, regardless of the nature of the recent stressful life events.     

Abnormal illness behavior and psychiatric disorders: a study in an outpatient clinic in Japan

Abnormal illness behavior, such as hypochondriacal attitude and inappropriate treatment-seeking, has been associated with various psychiatric disorders in which patients tend to abuse medical services and seek inappropriate treatment in general practice clinics rather than psychiatric clinics. However, the relationship between illness behavior and psychiatric disorders in Japan is yet to be elucidated. We examined the abnormal illness behavior of 243 patients who visited the outpatient department of psychiatry at Saga Medical School Hospital, Saga, Japan, using a Japanese version of the Illness Behavior Questionnaire (IBQ). Multivariate analysis indicated significant association between some of the IBQ scale scores and age, sex and employment status. Patients with anxiety disorder scored higher on five of the seven IBQ scales compared with patients with another major disorder (mood disorder, schizophrenia or somatoform disorder). When compared with the IBQ scale scores reported in Australian patients in a psychiatric hospital, most of the IBQ scale scores differed significantly in our patients; a higher score among Japanese patients on the general hypochondriasis scale was most prominent. A similar trend in IBQ scale scores was also noted among Japanese patients visiting the hospital's general medicine clinic in comparison with Australian patients visiting a general practice clinic. Japanese patients with anxiety disorder may display the most salient abnormal illness behaviors among patients with psychiatric disorders. Sociocultural background may contribute to the characteristic abnormal illness behaviors of Japanese patients.     

Ways of coping with asthma in everyday life: Validation of the Asthma Specific Coping Scale

Objective: This study examines the validity of the Asthma Specific Coping Scale. Methods: Study samples were comprised of persons with drug-treated asthma (n=3464) drawn from the Drug Reimbursement Registry and asthma rehabilitation participants [brief (n=278) and comprehensive (n=316) intervention]. Data were collected by questionnaires. Results: The expected structure of the six subscales (restricted lifestyle, hiding asthma, positive reappraisal, information seeking, ignoring asthma, and asthma worry) was supported. The Cronbach's reliabilities of the subscales ranged from .63 to .84. Concurrent validity was supported by meaningful correlations between asthma coping scales and psychosocial resources, health-related quality of life, and general coping. The asthma coping scales discriminated between the intervention participants and the population-based sample. Four out of six subscales also showed sensitivity to change after rehabilitation. Conclusion: Though further longitudinal studies are needed, this scale seems to be a promising instrument to be used in surveys and outcome studies.     

Illness worry and disability in fibromyalgia syndrome

Fibromyalgia (FM) is a common syndrome of functional somatic symptoms. This article examines whether an amplifying somatic style (increased body awareness and illness worry) might explain the distress and disability expressed by FM patients. Twenty FM patients were compared to twenty-three rheumatoid arthritis (RA) patients on measures of depressive and somatic symptomatology, pain, disability, and amplifying somatic style. FM patients reported greater somatic symptomatology, equivalent levels of pain, and less physical disability than did RA patients. No differences were observed between groups on body awareness or illness worry. Illness worry correlated highly with symptomatology for both groups but with physical disability only among FM patients. Results suggest that disability in functional somatic syndromes may be determined by patients' worry about having a serious disease. Feelings of vulnerability and apprehension about having an illness of unknown origin may contribute to FM sufferers' activity limitations, inability to sustain a work effort, and varied somatic distress.     

The Illness Behavior Assessment Schedule: reliability and validity

A patient's illness behavior represents an important component of any clinical presentation, and may in itself be pathological. Illness behavior and abnormal illness behavior are not easily evaluated, and considerable disagreement exists as to the criteria for making diagnoses such as "conversion reaction," "hypochondriacal reaction," etc. This paper describes the background, reliability and validity of the Illness Behavior Assessment Schedule (IBAS) which has been developed as a basis for a systematic and standardized approach to illness behavior.     

Distress and attitudes in patients perceived as hypochondriacal by medical staff

The aim of this study was to examine the characteristics of patients perceived by general physicians as hypochondriacal. The authors requested physicians at a general hospital to refer patients for a study of hypochondriasis. In order to measure depression, anxiety, and somatic symptoms, the authors administered several rating and self-rating scales, and to measure hypochondriacal attitudes they administered the Illness Attitude Scales (IAS) and the Illness Behavior Questionnaire (IBQ). The referred patients (N = 29) had more psychiatric disorders, were more depressed and more anxious, and had more severe somatic symptoms than matched medical patients who had not been referred. Self-rated hypochondriacal fears and beliefs did not differ significantly between the groups. Five of the referred patients (17%) whose initial diagnosis was hypochondriasis were subsequently found to have physical diseases that accounted for their symptoms. The implications of these findings for treatment are discussed.     

Hypochondriacal beliefs and attitudes in family practice and psychiatric patients

Beliefs and attitudes which can be responsible for hypochondriacal behavior were explored by administering the Illness Attitude Scales and two distress scales to patients attending a family practice clinic, nonpsychotic psychiatric outpatients and a random group of employees. Family practice patients were more distressed, had more hypochondriacal concerns and had more bodily preoccupations than employees and took more precautions about their health. Psychiatric patients were more distressed and had more fears about illness and death than family practice patients, yet took fewer precautions about their health. The findings appear to have implications for treatment.     

Hypochondriacal fears and beliefs in pregnancy

Illness attitudes were evaluated in 26 pregnant women and 26 control subjects matched for sociodemographic variables, by means of a self-rating scale, on 3 different occasions. For each trimester of pregnancy, women displayed more hypochondriacal fears and beliefs and conviction of disease (disease phobia) than normal controls. In the third trimester, they also reported more fear of dying and bodily preoccupations. The findings should alert physicians to ask their pregnant patients whether they are preoccupied with fear of dying, or are concerned that they suffer from an undiagnosed physical illness, or dread a specific illness such as cancer or heart disease. Hypochondriacal fears and beliefs are liable to affect well-being and the health attitudes of pregnant women. If properly recognized, they may effectively be treated.     

The Italian version of the obsessive compulsive inventory: its psychometric properties on community and clinical samples

The aim of the study was to evaluate psychometric properties of the Obsessive Compulsive Inventory (OCI) on Italian community and clinical samples. The Italian version of the 42-item OCI was administered to a sample of 340 individuals belonging to the general population and to 88 patients with obsessive compulsive (OCD) or other anxiety disorders. Four different internal structures of the OCI were compared through confirmatory factor analysis (CFA): the figures for the model with six factors and 18 items (OCI-R) met the best criteria for adequacy of fit. The six scales showed on average a 10% of common variance in the community sample and 8% in the clinical sample. The OCI-R subscales showed good internal consistency and temporal stability, with the exception of washing and mental neutralizing subscales which showed a strong alpha coefficient only in the OCD sample. Psychometric data for the OCI-R were insensitive to age and sex, whereas an effect of education was found. Concurrent validity was demonstrated, since the OCI-R subscales showed a pattern of specific correlations with another conceptually related self-report measure. Moreover, although the OCI-R was positively correlated with measures of depression, anxiety, and worry, the correlations were weaker than those with the other measure of OCD symptoms. The OCI-R clearly differentiated OCD patients from non-OCD anxious patients and nonclinical controls with the exception of hoarding subscale. However, the hoarding scale discriminated OCD patients who presented hoarding symptoms from OCD counterparts without such symptoms. Thus, the OCI-R proved to be a reliable and valid measure of obsessive compulsive symptoms in the Italian context.     

Intolerance of uncertainty, hypochondriacal concerns, obsessive-compulsive symptoms, and worry

Intolerance of uncertainty (IU) has been found to be involved in several anxiety disorders, including generalized anxiety disorder and obsessive-compulsive disorder (OCD). Few studies have examined the role of IU in health anxiety (HA)/hypochondriacal concerns (HC). We conducted two studies exploring the associations between IU and HA/HC. The first study included undergraduates (n = 114) and indicated an association between IU and several HA/HC indices. When controlling for neuroticism, worry about illness was the single index of HA/HC that remained associated with IU. In the second study among bereaved adults (n = 126), IU was associated with one index of HA/HC but not when neuroticism and anxiety sensitivity were controlled. In both studies, IU was found to be more strongly associated with OCD symptoms and worry than with HA/HC.     

Sleep quality in treatment-seeking veterans of Operations Enduring Freedom and Iraqi Freedom: the role of cognitive coping strategies and unit cohesion

Objective

Sleep difficulties are common in individuals exposed to stress or trauma, and maladaptive cognitive coping strategies, such as worry and fear of losing vigilance, as well as low social support, may further impair sleep quality. This study examined the severity and correlates of sleep difficulties in a sample of treatment-seeking veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF).

Method

A total of 167 OEF-OIF veterans seeking behavioral or primary care services completed a questionnaire containing measures of sleep quality, combat exposure, psychopathology, fear of loss of vigilance, cognitive coping strategies, and unit and postdeployment social support within 1 year of returning from deployment.

Results

Mean Pittsburgh Sleep Quality Inventory scores in the full sample were indicative of severely impaired sleep. Posttraumatic stress disorder (PTSD) was associated with increased sleep difficulties, most notably sleep disturbances, daytime dysfunction, and sleep quality. Hierarchical regression analysis in the full sample revealed that PTSD symptoms and scores on measures of worry and fear of loss of vigilance were positively associated with sleep difficulties and that scores on a measure of unit member support were negatively associated with sleep difficulties. Among veterans with PTSD, fear of loss of vigilance was positively associated with sleep difficulties and cognitive distraction and unit member support were negatively associated with sleep difficulties.

Conclusions

Treatment-seeking OEF-OIF veterans report severe sleep difficulties, with more pronounced impairment in veterans with PTSD. The results of this study suggest that interventions to mitigate worry and fear of loss of vigilance and to enhance perceived unit member support may be helpful in reducing sleep difficulties following return from deployment in this population.