Issy Pilowsky

Pain, depression, and illness behavior in a Pain Clinic population

&NA; The relationship between depression, illness behavior and persistent pain was studied in 100 patients referred to the University of Washington Hospital Pain Clinic. The instruments used were the Illness Behavior Questionnaire (IBQ) and the Levine‐Pilowsky Depression Questionnaire (LPD). To delineate those aspects of illness behavior characteristic of the Pain Clinic group, their scores were compared to those attained on the IBQ by a Family Medicine Clinic sample. The Pain Clinic group showed greater conviction of disease and somatic preoccupation than the comparison group. Further, they were reluctant to consider their health problems in psychologic terms, and denied current life problems. The Pain Clinic groups performance on the LPD indicated a low degree of depressive affect overall and few patients manifesting a depressive syndrome. The association between IBQ and depression scores suggests that the predominant clinical pattern presented by pain clinic patients is best characterized as a form of “abnormal illness behavior”.

A controlled study of amitriptyline in the treatment of chronic pain.

Abstract This paper reports a study in which a double‐blind controlled cross‐over study of amitriptyline vs. placebo was carried out in a group of patients referred to a multidisciplinary pain clinic for the management of chronic intractable pain for which no substantial organic cause could be demonstrated. Of 52 patients entering the 12‐week trial, 20 withdrew before completion. No differences were found in terms of global improvement on either agent. Subjective reports indicated a greater reduction in pain at 2 and 4 weeks on amitriptyline, but no difference at 6 weeks. None of the baseline measures was predictive of response.

Illness behaviour syndromes associated with intractable pain

&NA; One hundred patients, referred for the management of intractable pain, completed a 52‐item Illness Behaviour Questionnaire (IBQ). Responses were scored on 7 scales: general hypochondriasis, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial, and irritability. IBQ scale profiles were subjected to numerical analysis and 6 taxonomic clusters were identified. Patients in groups 1–3 were characterized by a relatively non‐neurotic, reality‐oriented attitude to illness, as indicated by low scores on the first three scales. Patients in groups 4–6 manifested greater evidence of ‘abnormal illness behaviour’, and presented syndromes resembling ‘hysteria’, ‘conversion reaction’, and ‘hypochondriasis’ respectively.

The development of a screening method for abnormal illness behaviour

Abstract The 62-item Illness Behaviour Questionnaire (IBQ) was administered to 100 Pain Clinic patients and 78 General Practice patients in Seattle, Washington; and to 100 Pain Clinic patients and 155 General Practice patients in Adelaide, South Australia. A discriminant function which included scores on Scale 2 (disease conviction), Scale 3 (somatic focusing), Scale 6 (denial) and Scale 7 (irritability) was derived from the scores of the Seattle populations. When this function was applied to the Adelaide populations, the IBQ was found to have a sensitivity of 97%, specificity of 73.55% and hits-positive rate of 0.70. It appears, therefore, that the IBQ may be successfully utilized as a screening instrument in General Practice populations to identify patients manifesting abnormal illness behaviour.

An outline curriculum on pain for medical schools

Although most formal decisions as to the management of pain are made by doctors, it has been obvious for a long time that medical undergraduate teaching on the subject of pain leaves much to be desired. Many medical schools teach very little about pain at either the preclinical or clinical levels and information is poorly integrated. Changing medical undergraduate curricula is never an easy task. It is one which needs to be catalysed and facilitated in a variety of ways. As part of its aim to increase educational standards in the field of pain IASP set up an Ad Hoc Sub-committee on Medical School Courses and Curriculum in November 1985. The members of the committee represent the entire range of disciplines with an interest in pain and include: Issy Pilowsky (Chairman), Michael R. Bond, John J. Bonica, Harald Breivik, C. Richard Chapman, Arthur W. Duggan, Robert G. Large, John D. Loeser, Patrick J. McGrath, Arthur G. Lipman, Francois Boureau, Richard Payne, Ann PiquardGauvin, Paulo Procacci, Bruce F. Rounsefell, Bengt SjtYund and Eldon R. Tunks. The committee set itself the task of producing an outline model pain course which would indicate in the form of a list of topics, the issues which should be covered in a medical undergraduate curriculum. Each member of the committee was asked to provide a list of subjects. These were combined into a single list which was circulated to all members and after revision an agreed version was submitted to Council at its August 1987 meeting where it was accepted. The chief purpose of this editorial is to make the Pain Curriculum Outline available to a wide audience in the hope that it might stimulate comments, criticisms and suggestions. The committee hopes that those involved in Medical School Curriculum planning might use the Outline to draw the attention of their colleagues to the areas which ought to be covered if medical graduates are to be adequately prepared for the management of pain. We realize, of course, that there are as many ways of covering the topics in the Outline as there are medical schools. We hope, however, that the Model Curriculum we have proposed will provide useful guidelines and we have purposely avoided offering suggestions on how these might be put into practice in terms of hours or location in the curriculum.

Depressive symptoms and abnormal illness behavior in general hospital patients

There have been many accounts of depression and abnormal illness behavior in medical inpatients, but systematic studies of their prevalence and features in a general hospital are lacking. Occurrence and characteristics of depression and illness behavior were studied in 325 inpatients of a general hospital in the northern part of Italy. Patients were surveyed in six separate wards (medicine, surgery, dermatology, OB-GYN, orthopedics, and ophthalmology) and represented about 90% of their actual population during a one-week period. Two self-report scales were used for screening: the CES-D (scale devised by the Center for Epidemiologic Studies of Depression at NIMH) for measuring depression and the Illness Behavior Questionnaire (IBQ), developed by Pilowsky and Spence. Both scales were administered in their validated Italian translations. The customary cut-off point of 16 in the CES-D score revealed about 58% of the patients as depressed. A more conservative cut-off point of 23 still showed 33.5% of the patients as depressed. The IBQ scores of the depressed patients showed significantly (p less than 0.001) higher levels of general hypochondriasis, disease conviction, dysphoria, and irritability than the nondepressed patients. No relevant differences existed between wards in the amount of depression and IBQ scores, even when differences were adjusted for age, sex, marital status, and social class. Implications for psychosomatic research (sociodemographic characteristics of depression and illness behavior, bias in comparing hospital patients and controls in the general population, and so on) and treatment (consultation-liaison psychiatry) are discussed.

Temporo-mandibular joint dysfunction : Pain and illness behaviour

Abstract This study investigated prospectively the illness behaviour of 100 patients with temporo‐mandibular (TMJ) dysfunction and 100 asymptomatic patients. It has previously been shown that a simple illness behaviour questionnaire (IBQ) can discriminate between patients with intractable facial pain and minor odontogenic pain [28]. The purpose of this study was to determine whether it was possible to prospectively identify those patients who may be resistant to conservative therapy. The results showed that the TMJ dysfunction patients had significantly increased levels of disease conviction (P < 0.001), anxiety or depression (P < 0.005), and were less likely to deny the existence of problems in their life (P < 0.05) compared to control patients. However, the TMJ population was much closer to the control population than to a pain clinic population. In the small percentage (13%) of patients who failed to respond to conservative therapy, over half showed abnormal illness behaviour. Seventy‐five percent of all the TMJ patients could be excluded from further assessment of abnormal illness behaviour at little risk of incorrect classification. Thus the illness behaviour questionnaire can be used as a screening device to identify those patients who require psychologic treatment rather than more aggressive surgical treatment.

Illness behaviour and general practice utilisation: A prospective study

The Illness Behaviour Questionnaire (IBQ) was used to compare general practice patients who presented physical complaints in the absence of objective pathology, with those in whom the presence of pathology was established. Patients without pathology showed a greater conviction as to the presence of disease, and greater degrees of anxiety, depression and irritability. Males and females differed on their IBQ scores: males showing more disease conviction, somatic focusing and hypochondriasis. Utilisation of general practitioner services (as indicated by the number of visits in the six months subsequent to completing the IBQ) was associated with greater age, and for the group as a whole, utilisation was predicted by higher scores on the following IBQ scales: disease conviction, affective disturbance and disease affirmation. This was also the case for males, but in females only affective disturbance correlated with a greater number of visits. Four patterns were delineated in the relationship between age, illness behaviour variables, the presence or absence of objective pathology, and G.P. contacts.

The Illness Behavior Questionnaire as an Aid to Clinical Assessment

The Illness Behavior Questionnaire (IBQ) is a 62-item self-report instrument that provides information relevant to the delineation of a patients attitudes, ideas, affects, and attributions in relation to illness. The scores generated are described, and nine clinical vignettes are presented, together with IBQ score profiles and interpretations to illustrate the manner in which the latter may complement other clinical data. The ways in which individuals react to their own health status is becoming of greater importance as the taking of responsibility for ones own health is increasingly emphasized. The IBQ provides information that should be relevant to the management of patients, regardless of the specific nature of their illness.

The response to treatment in a multidisciplinary pain clinic.

Abstract Reports of the results obtained by multidisciplinary pain clinics are reviewed. The outcome of management of a cohort of patients referred to the Royal Adelaide Hospital Pain Clinic is described. Thirty‐seven percent of patients reported partial or complete relief. The problems of assessing outcome are discussed, as well as the difficulty of making meaningful comparisons between pain clinics. The evidence thus far available suggests that multidisciplinary pain clinics make a useful and important contribution to the management of pain syndromes.