Causal illness attributions in somatoform disorders: associations with comorbidity and illness behavior

OBJECTIVE: To compare causal illness beliefs between patients with unexplained physical symptoms and different comorbid disorders and to assess the association of causal illness beliefs with illness behavior. METHODS: We examined a sample of 233 patients attending treatment in primary care. Inclusion criteria were "unexplained physical symptoms." All patients were investigated using structured interviews and self-rating scales [Screening for Somatoform Symptoms (SOMS), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and a 12-item instrument to assess causal attributions]. By means of factor analysis, the following illness attributions were considered: vulnerability to infection and environmental factors, psychological factors, organic causes including genetic and aging factors, and distress (including exhaustion and time pressure). RESULTS: Most patients reported multiple illness attributions. The more somatoform symptoms patients had, the more explanations in general they considered. Especially for vulnerability and organic illness beliefs, patients with somatoform symptoms had increased scores. Comorbidity with depression and with anxiety disorders was associated with more psychological attributions. Even when the influence of somatization, depression, and anxiety is controlled for, illness beliefs still showed associations with illness behavior. Organic causal beliefs and vulnerability attributions were associated with a need for medical diagnostic examinations, increased expression of symptoms, increased illness consequences, and bodily scanning. CONCLUSIONS: Multiple causal attributions can coexist demonstrating different associations with comorbid depression and illness behavior.     

Psychiatric morbidity and cognitive representations of illness in chronic daily headache

OBJECTIVES: We studied patients with chronic daily headache (CDH) attending a headache clinic. Our hypothesis was that patients with anxiety or depression would have poorer functional status and differing cognitive representations of illness than would those without psychiatric morbidity. METHODS: The sample consisted of 144 consecutive new patients. Patients underwent a semistructured interview and completed a prospective headache diary, the Hospital Anxiety and Depression Scale (HADS) and other health-related questionnaires. RESULTS: Sixty patients (42%) were probable cases of anxiety or depression on the basis of their HADS score. These HADS-positive cases had longer, more severe headaches, were more worried about them, were more functionally impaired and believed that their illness would last longer. Principal components analysis revealed that the HADS-positive cases believed that psychological factors play a role in their headaches. CONCLUSIONS: Psychological morbidity is high amongst CDH patients who attend specialist clinics. In addition to identifying those with high levels of psychological distress, the HADS can be used to predict those likely to have worse headaches and poorer functional ability.     

The associations of anxiety, depression and personal illness representations with glycaemic control and health-related quality of life in patients with type 2 diabetes mellitus

OBJECTIVE: This study examined the interrelationships of anxiety, depression and personal illness representations with glycaemic control and health-related quality of life in adults with Type 2 diabetes. METHODS: One hundred eighty-four consecutive patients with Type 2 diabetes mellitus completed the Illness Perception Questionnaire (IPQ), the Well-Being Scale (WBQ) and the Short Form 36 Health Survey Questionnaire (SF-36). Demographic characteristics, details of diabetes status (duration of diabetes, treatments and complications) and glycosylated haemoglobin (HbA1c) were recorded. RESULTS: Depression was correlated with greater perceived symptom load (r = .48, P < .01), worse anticipated consequences (r = -.41, P < .01) and perceived lack of control of diabetes (r = .28, P < .01). After controlling for demographic and illness characteristics, personal illness representations relating to symptom load and anticipated consequences were independently associated with the SF-36 physical functioning score, contributing an additional 15% to the variance. WBQ depression and anxiety scores, along with IPQ control and consequences, were independently associated with SF-36 mental function score, contributing a further 51% to the variance after controlling for demographic and illness details. Neither IPQ nor WBQ scales were associated with HbA1c after controlling for demographic and medical illness details. CONCLUSION: Anxiety, depression and negative beliefs about illness influence physical and mental functioning, but not metabolic control in patients with diabetes.     

Alexithymia in adolescents with chronic fatigue syndrome

BACKGROUND: Alexithymia is postulated as an important factor in the development of medically unexplained physical symptoms. Chronic fatigue syndrome (CFS) is presently medically unexplained. The aim of this study was to investigate whether the prevalence of alexithymia was higher in adolescents with CFS compared to healthy adolescents. Comorbidity such as anxiety and depression were analyzed as possible confounding factors. Secondly, alexithymia was investigated as a prognostic factor for the recovery of CFS. METHODS: A cross-sectional study was performed among 40 adolescent outpatients diagnosed with CFS and 36 healthy controls. The 20-item Toronto Alexithymia Scale was used to assess all participants for alexithymia. Additionally, all participants completed a number of questionnaires regarding fatigue (Checklist Individual Strength), somatic complaints (Checklist Somatization Inventory), depression (Children's Depression Inventory), and trait anxiety (Spielberger State Trait Anxiety Questionnaire). A follow-up study was performed among the CFS adolescents 1 1/2 years after the initial assessment. RESULTS: CFS adolescents scored higher only on the subscale identifying feelings of the TAS-20 [mean difference after adjustment for depression and anxiety 2.8 (95% CI: 0.6; 4.9]. Twelve CFS adolescents (30%) fulfilled criteria for alexithymia. This subgroup was characterized by higher scores for depression and anxiety and equal scores for fatigue and somatic complaints. At follow-up, no differences in recovery were established between the alexithymic and nonalexithymic CFS adolescents. CONCLUSIONS: Alexithymia neither appears to be a unique correlate of CFS nor to be a prognostic factor for recovery of the CFS illness.     

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.     

Psychopathology and illness beliefs influence COPD self-management

OBJECTIVE: To explore the influence of psychological characteristics in Chronic Obstructive Pulmonary Disease (COPD) self-management. METHODS: Patients admitted with an exacerbation of COPD were interviewed for psychiatric symptoms, illness beliefs and self-management behaviour using a new COPD Self-Management Interview (COPD-SMI). This comprised three scenarios to mimic a future evolving exacerbation. Responses were scored for knowledge and actions (adherence) for each scenario. RESULTS: Of 47 people approached, 39 participated; 41% had panic attacks, 33% general anxiety, 35% a depression history, 31% an anxiety history and 21% an alcohol dependence history. Twenty-six (67%) had a self-management plan. When hypothetically "well" lower (poorer) COPD-SMI Knowledge Scores were associated with an alcohol dependence history (P=.025), no panic (P=.021) and males (P=.028). Those perceiving less influence over COPD had lower Action Scores during this scenario (P=.01) and the "early exacerbation" scenario (P=.05). Lower Knowledge Scores for the "early exacerbation" were associated with no panic (P=.01) and no self-management plans (P=.03). For the "severe exacerbation", lower Action Scores were associated with depression history (P=.004), panic (P=.002), higher FEV(1)% and no self-management plans (P=.005). Higher PaCO(2) was associated with lower confidence in symptom recognition, self-management ability and medical care influencing COPD. CONCLUSION: Anxiety, depression, alcohol use and illness beliefs may differentially influence self-management. Depression, previous alcohol dependence and perceived less influence over COPD inhibited self-management. Those with panic demonstrated more self-management knowledge when "well" but performed poorly on actions during the "severe exacerbation". Those with self-management plans had better knowledge and actions.     

Functional status,neuropsychological functioning,and mood in chronic fatigue syndrome (CFS): relationship to psychiatric disorder

Individuals with chronic fatigue syndrome (CFS) face chronic physical debilitation, reduced neuropsychological functioning, and changes in emotional well-being that significantly detract from quality of life. The role of psychiatric disturbance in reducing quality of life in CFS remains unclear. In the current investigation, the role of psychiatric status in reducing health-related quality of life in CFS was examined. Four subject groups were compared on measures of functional well-being, mood, and neuropsychological status: individuals with CFS and no history of psychiatric illness, individuals who had current symptoms of psychiatric illness that began after their CFS diagnosis, individuals who had current symptoms of psychiatric illness that began before their CFS diagnosis, and a healthy sedentary control group. Overall, it was found that individuals with CFS suffer from profound physical impairment. Concurrent psychiatric illness, however, did not adversely affect physical functional capacity. Physical functional capacity was not worse in individuals with a concurrent psychiatric illness. As expected, concurrent psychiatric illness was found to reduce emotional well-being. Moreover, individuals with a psychiatric illness that predated the onset of CFS suffered the greatest emotional distress. Thus, an individual's psychiatric history should be considered when attempting to understand the factors maintaining disability in CFS.     

Factors affecting anxiety and depression in psychiatric consultation patients

Factors that contribute to dysphoric affects in patients seen on a consultation-liaison service were investigated. Eighty-five subjects were studied to assess the role of character style, locus of control and seriousness of medical illness upon the magnitude of depression and anxiety each patient experienced. Results indicated that the obsessoid individual as well as individuals in pain reported significantly more depression and anxiety than their hysteroid counterparts. The severity of illness did not correlate with greater dysphoria. Those individuals who were more externally located were found to be in greater subjective pain. Furthermore, psychiatric consultants significantly tended to ignore the issue of the pain more often than anxiety and depression. The implications of these findings are discussed as they relate to a patient's personality style and the experience of illness and hospitalization.     

Psychological correlates of functional status in chronic fatigue syndrome

Background: The present study was designed to test a cognitive model of impairment in chronic fatigue syndrome (CFS) in which disability is a function of severity of fatigue and depressive symptoms, generalized somatic symptom attributions and generalized illness worry. Methods: We compared 45 CFS and 40 multiple sclerosis (MS) outpatients on measures of functional ability, fatigue severity, depressive symptoms, somatic symptom attribution and illness worry. Results: The results confirmed previous findings of lower levels of functional status and greater fatigue among CFS patients compared to a group of patients with MS. Fatigue severity was found to be a significant predictor of physical functioning but not of psychosocial functioning in both groups. In CFS, when level of fatigue was controlled, making more somatic attributions was associated with worse physical functioning, and both illness worry and depressive symptoms were associated with worse psychosocial functioning. Conclusions: Our findings support the role of depression and illness cognitions in disability in CFS sufferers. Different cognitive factors account for physical and psychosocial disability in CFS and MS. The SF-36 may be sensitive to symptom attributions, suggesting caution in its interpretation when used with patients with ill-defined medical conditions.     

Cognitive functioning in chronic fatigue syndrome and the role of depression,anxiety, and fatigue

Objective: This study was designed to investigate the role of depression, anxiety, and fatigue in Chronic Fatigue Syndrome (CFS) sufferers' objective and subjective cognitive performance. Methods: Twenty-three CFS sufferers and 23 healthy control participants were compared on objective and subjective assessments of cognitive performance. Depression, anxiety, and fatigue were also evaluated. Results: CFS sufferers did not demonstrate any impairment in objective cognitive functioning compared to the control group, and objective performance was not related to their higher levels of depression or their level of fatigue. Depression scores only accounted for a small amount of the variance in CFS sufferers' lower subjective assessment of their cognitive performance compared to control participants. There were no differences between the groups on anxiety scores. Conclusion: The results are discussed in terms of the heterogeneity of the CFS population and the complex interaction of symptomatological factors that characterise CFS.     

Illness perceptions and mood in chronic fatigue syndrome

BACKGROUND: Individual beliefs and cognitions may affect adjustment to chronic fatigue syndrome (CFS) and illness perceptions, in particular, have been reported to correlate with both disability and psychological adjustment to CFS in self-diagnosed cases. OBJECTIVES: The aim of the present study was to examine these relationships in a clinic sample of CFS patients assessed by both a physician and psychiatrist. METHOD: A sample of 173 patients referred to a multidisciplinary CFS clinic and fulfilling current operational criteria for CFS [Ann Intern Med 121 (1994) 953; J R Soc Med 84 (1991) 118.] were randomly selected from the clinic database and surveyed with the Hospital Anxiety and Depression scale, Fatigue Questionnaire and Illness Perceptions Questionnaire [J Psychosom Res 37 (1993) 147; Psychol Health 11 (1996) 431; Acta Psychiatr Scand 67 (1983) 361.]. RESULTS: A total of 126 patients responded (73% response rate). The illness perception components studied were consequences (of illness), illness identity, causes (of illness), the ability to control/cure the illness and (expected) timeline of the illness. These components accounted for 15%, 28% and 30% of the variance in levels of fatigue, depression and anxiety, respectively. Two of the illness perception components (consequences and illness identity) were stronger predictors of fatigue score than mood scores. CONCLUSIONS: These findings confirmed in a clinical sample that illness perceptions are associated with variation in both disability and psychological adjustment in CFS. Illness perceptions may have an important and long-lasting effect on adaptation to CFS, and it is necessary to have a greater understanding of their role in order to tailor effective interventions for the condition.     

Illness perceptions and levels of disability in patients with chronic fatigue syndrome and rheumatoid arthritis

OBJECTIVE: To investigate the strength of chronic fatigue syndrome (CFS) patients' negative illness perceptions by comparing illness perceptions and self-reported disability in patients with CFS and rheumatoid arthritis (RA). METHODS: Seventy-four RA patients and 49 CFS patients completed the Illness Perception Questionnaire-Revised and the 36-item Short-Form Health Survey. RESULTS: When compared to the RA group, the CFS group attributed a wider range of everyday somatic symptoms to their illness, perceived the consequences of their illness to be more profound and were more likely to attribute their illness to a virus or immune system dysfunction. Both groups reported equivalent levels of physical disability but the CFS group reported significantly higher levels of role and social disability. CONCLUSION: Although the symptoms of CFS are largely medically unexplained, CFS patients have more negative views about their symptoms and the impact that these have had on their lives than do patients with a clearly defined and potentially disabling medical condition. The data support the cognitive behavioural models of CFS that emphasise the importance of patients' illness perceptions in perpetuating this disorder.     

Primary care patients' personal illness models for depression: relationship to coping behavior and functional disability

OBJECTIVE: The applicability and clinical utility of Leventhal et al.'s model of illness cognition were evaluated in depressed primary care patients. The intercorrelations of illness beliefs and the mediational effects of coping behavior on these beliefs were also evaluated. Moderating effects of coping behaviors were explored. METHODS: Baseline evaluations of demographic information, depression diagnoses, depressive symptom severity, self-reported psychosocial and physical functioning, medical comorbidity, illness beliefs and depression coping strategies were obtained from 191 primary care patients receiving antidepressant medication for the treatment of depression. RESULTS: Patients' beliefs about depressive symptoms, causes, duration as well as controllability and the consequences of these symptoms are described. Leventhal et al.'s mediational model was partially supported for the outcome of psychosocial functioning. Coping behavior did not mediate the relationship between illness beliefs and physical functioning. The relationships between participants' beliefs about the cause, controllability and duration of depressive symptoms were mediated by the use of behavioral disengagement, venting or self-blame as a strategy to cope with depression. In addition, use of acceptance, religious coping or behavioral disengagement moderated the relationship between beliefs about the cause of depression (i.e., environment or chance or medical illness) and psychosocial functioning. CONCLUSIONS: Illness models for depression are important determinants of functioning in depressed primary care patients. These beliefs and coping behaviors are potentially modifiable and could be the target of interventions to decrease functional impairment in depressed patients.     

Illness Beliefs in Chronic Fatigue Syndrome: A Study Involving Affected Adolescents and their Parents

Background:  The aim of the study was too investigate the beliefs of young people with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) and their parents, about illness causes and management.
Method:  Twenty-one young people with CFS/ME and their parents participated in an open-ended interview.
Results:  Infective causes were identified by the majority of respondents, and psychological ones by a minority. Many highlighted reducing activity and resting in symptom management. Positive and negative experiences of psychiatric and psychological treatments were recorded.
Conclusion:  Professionals should carefully explore the illness related beliefs of young people with CFS/ME and parental beliefs in order to agree treatment plans.     

Sex differences in mental illness: a community study of the influence of physical health and sociodemographic factors

Summary This paper examines sex differences in psychiatric morbidity, using data from a community sample. The PSE-CATEGO-ID system was used to evaluate psychopathology. Six sociodemographic factors and physical illness were taken as independent variables. Females exhibit both a significantly higher psychiatric morbidity than males and a predominance of syndromes closely related to depression (SD; OD syndromes) and anxiety (GA; SA; TE; IT syndromes). Logistic modelling analysis, carried out separately for each sex, yielded different models. Psychiatric illness in men was best predicted by physical illness, unemployment and the interaction between the two. In contrast, physical illness emerged, in women, as the only factor exerting significant effects on psychiatric morbidity.     

Mental, physical and functional status in primary care attenders

OBJECTIVE: The purpose of the present study was to analyze the association, in primary care attenders, between psychiatric disorders, medical comorbidity, and impairment in mental and physical function status. METHODS: The study had a two-stage design. The GHQ-12 was used to screen 1647 patients, and 323 of them were then interviewed using the CIDI-PHC to obtain ICD-10 diagnoses. Severity of mental illness was assessed using the Hamilton scales for anxiety and depression. The DUSOI was used to evaluate the severity of physical illness. The MOS SF-36 was used to assess health related quality of life. RESULTS: The estimated prevalence of ICD-10 psychiatric disorders and subthreshold disorders was 12.4 percent and 18 percent respectively. The most common psychiatric disorders were generalized anxiety, major depression, and neurasthenia. The severity of physical illness did not vary across diagnostic status categories. Significant impairment, both in physical and mental functioning was seen in patients suffering from ICD-10 full-fledged and subthreshold disorders. Severity of impairment increased from sub-threshold cases to full-fledged cases, and among the latter according to the severity of depressive and anxious symptoms, assessed using Hamilton scales. The most frequent psychiatric disorders were associated with significant worsening in health related quality of life, with relevant differences between psychiatric diagnoses regarding the domains affected. Impairment associated with mental disorders was greater than that associated with physical illness. CONCLUSIONS: The results of the present study confirm that ICD-10 psychiatric disorders are common in general practice and are associated with relevant impairment in physical and mental functional status. Psychiatric morbidity is not related to severity of physical illness rated by general practitioner.     

Prevalence,recognition and management of mental disorders in primary health care in Northern Jordan

This study examined the prevalence of psychiatric disorders and assessed factors that are assumed to be related to recognition of this morbidity among clinical patients. A total of 794 patients aged 18 years or older participated in the study. Using an Arabic-translated version of the General Health Questionnaire (GHQ-28), the prevalence of psychiatric morbidity was found to be 61%. The highest prevalence rates of psychiatric disorders were found in the 40 years and older age group, in female subjects, in uneducated and highly educated groups, in unemployed individuals, and in patients who were perceived to have ‘fair’ or ‘poor’ physical health. Multiple logistic regression analysis revealed that unemployment and perceived severity of physical illness were positively correlated with psychiatric disorders, but no significant correlation was found with sex, age or level of education. The physicians in the present study were able to detect morbidity in only 24% of the patients. Among patients with psychiatric disorders, recognition of this morbidity was significantly greater in women, in patients who had consulted with their family doctors, in patients previously known to their physicians, and in patients with mild physical illness than in their counterparts. The most common lines of psychiatric management used in this study were referral to psychiatrists (47%) and psychotropic medication (16%).     

Associations between perfectionism, mood, and fatigue in chronic fatigue syndrome: a pilot study.

This study investigated possible associations between perfectionistic personality traits, mood, and fatigue in chronic fatigue syndrome (CFS). Forty CFS sufferers referred to tertiary care and 31 control healthy subjects completed the Multidimensional Perfectionism Scale (MPS), Chalder Fatigue Questionnaire, and Hospital Anxiety and Depression (HAD) scale. Total perfectionism scores did not correlate with fatigue, anxiety, or depression in either group. Other-oriented MPS scores were significantly lower among CFS sufferers (p = .0019), especially women, and correlated negatively with physical fatigue levels overall (R = -0.27, p = .02). Total and socially prescribed MPS scores correlated with age for the CFS group alone (p = .05). Possible reasons why this study did not confirm a positive association between perfectionism and CFS are discussed. The finding that CFS sufferers set lower standards and have lower expectations for significant others may have implications for rehabilitation and recovery from this disorder.     

Depression in relation to anxiety, obsessionality and phobia among neurosurgical patients with a primary brain tumor: a 1-year follow-up study

Depression is found to be present in up to 44% of brain tumor patients during their illness process. Anxiety as a comorbid psychiatric disorder with depression has formerly been studied, but phobia or obsessive-compulsive symptoms among brain tumor patients have not yet been noticed.By using a clinical prospective database of primary brain tumor patients (n = 77) we studied the level of depression, anxiety, obsessionality (traits and symptoms) and phobic anxiety symptoms. Psychiatric symptoms were assessed before tumor operation as well as at three months and at one year after operation. The presence of comorbid anxiety, obsessionality and phobic anxiety symptoms was assessed before operation and at follow-ups in depressed and non-depressed patients, separately.Before tumor operation 16% of the patients had depression according to Beck Depression Inventory (BDI), while 10% had depression at three months and 15% at one year after operation.The depressed patients had statistically significantly higher anxiety scores and phobic scores at all three measurement points compared to corresponding scores among non-depressed brain tumor patients. The mean obsessionality scores among depressed brain tumor patients were significantly higher when measured before operation and at one year after the operation compared to non-depressed patients.To our knowledge, this is the first study so far in which comorbidity of psychiatric symptoms has been shown among depressive brain tumor patients. Concurrent comorbid conditions have been shown to be associated with increased severity, morbidity and chronicity of depression. It is recommended that treatment of depressive patients complicated with comorbid psychiatric disorders be planned by psychiatric units.     

Chronic fatigue syndrome: A qualitative investigation of patients'' beliefs about the illness

The chronic fatigue syndrome is a disabling chronic condition of uncertain cause. Previous studies have found that patients seen in hospital clinics with the syndrome often strongly believe that their illness is physical in nature and minimize the role of psychological and social factors. There is also evidence that patients cope by avoiding activity. However, almost all of these studies have assessed illness beliefs only by questionnaire. The aim of this study was to explore the nature and origin of illness beliefs in more detail using in-depth interviews and a qualitative analysis of patient responses. Sixty-six consecutive referrals meeting Oxford criteria for chronic fatigue syndrome were recruited. Analysis of responses indicated that, whereas the most commonly described explanation for the illness was a physical one, more than half the patients also believed “stress” had played a role. Patients believed that they could partially control the symptoms by reducing activity but felt helpless to influence the physical disease process and hence the course of the illness. Patients reported that they had arrived at these beliefs about the illness after prolonged reflection on their own experience combined with the reading of media reports, self-help books, and patient group literature. The views of health professionals played a relatively small role. There is potentially a considerable opportunity to help patients arrive at a wider and more enabling explanation of their illness when they first present to primary care.