James M. Robbins

Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics.

Three definitions of somatization were operationalized: (a) high levels of functional somatic distress, measured by the Somatic Symptom Index (SSI) of the Diagnostic Interview Schedule; (b) hypochondriasis measured by high scores on a measure of illness worry in the absence of evidence for serious illness; and (c) exclusively somatic clinical presentations among patients with current major depression or anxiety. Of 685 patients attending two family medicine clinics, 26.3% met criteria for one or more forms of somatization. While DSM-III somatization disorder had a prevalence of only 1% in this population, 16.6% of the patients met abridged criteria for subsyndromal somatization disorder (SSI 4,6). Hypochondriacal worry had a prevalence of 7.7% in the clinic sample. Somatized presentations of current major depression or anxiety disorder had a prevalence of 8%. The three forms of somatization were associated with different sociodemographic and illness behavior characteristics. A majority of patients met criteria for only one type of somatization, suggesting that distinct pathogenic processes may be involved in each of the three types.

Attributions of common somatic symptoms

Three studies explored the causal attributions of common somatic symptoms. The first two studies established the reliability and validity of a measure of attributional style, the Symptom Interpretation Questionnaire (SIQ). Three dimensions of causal attribution were confirmed: psychological, somatic and normalizing. The third study examined the antecedents and consequences of attributional style in a sample of family medicine patients. Medical and psychiatric history differentially influenced attributional style. Past history and attributional style independently influenced clinical presentations over the subsequent 6 months. Symptom attributional style may contribute to the somatization and psychologization of distress in primary care.

Fatigue in primary care: prevalence, psychiatric comorbidity, illness behavior, and outcome.

Objectives:To identify the prevalence, psychiatric comorbidity, illness behavior, and outcome of patients with a presenting complaint of fatigue in a primary care setting.Methods:686 patients attending two family medicine clinics on a self-initiated visit completed structured interviews for presenting complaints, self-report measures of symptoms and hypochondriasis, and the Diagnostic Interview Schedule (DIS). Fatigue was identified as a primary or secondary complaint from patient reports and questionnaires completed by physicians.Results:Of the 686 patients, 93 (13.6%) presented with a complaint of fatigue. Fatigue was the major reason for consultation of 46 patients (6.7%). Patients with fatigue were more likely to be working full or part time and to be French Canadian, but did not differ from the other clinic patients on any other sociodemographic characteristic or in health care utilization. Patients with fatigue received a lifetime diagnosis of depression or anxiety disorder more frequently than did other clinic patients (45.2% vs. 28.2%). Current psychiatric diagnoses, as indicted by the DIS, were limited to major depression, diagnosed for 16 (17.2%) fatigue patients. Patients with fatigue reported more medically unexplained physical symptoms, greater perceived stress, more pathologic symptom attributions, and greater worries about having emotional problems than did other patients. However, only those fatigue patients with coexisting depressive symptoms differed significantly from nonfatigue patients. Patients with fatigue lasting six months or longer compared with patients with more recent fatigue had lower family incomes and greater hypochondriacal worry. Duration of fatigue was not related to rate of current or lifetime psychiatric disorder. One half to two thirds of fatigue patients were still fatigued one year later.Conclusions:In a primary care setting, only those fatigue patients who have coexisting psychological distress exhibit patterns of abnormal illness cognition and behavior. Regardless of the physical illnesses associated with fatigue, psychiatric disorders and somatic amplification may contribute to complaints of fatigue in less than 50% of cases presented to primary care.

Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics.

We examined the cognitive and sociodemographic characteristics of patients making somatic presentations of depression and anxiety in primary care. Only 15% of patients with depressive symptomatology on self-report, and only 21% of patients with current major depression or anxiety disorders on diagnostic interview, presented psychosocial symptoms to their GP. The remainder of patients with psychiatric distress presented exclusively somatic symptoms and were divided into three groups-initial, facultative and true somatizers-based on their willingness to offer or endorse a psychosocial cause for their symptoms. Somatizers did not differ markedly from psychologizers in sociodemographic characteristics except for a greater proportion of men among the true somatizers. Compared to psychologizers, somatizers reported lower levels of psychological distress, less introspectiveness and less worry about having an emotional problem. Somatizers were also less likely to attribute common somatic symptoms to psychological causes and more likely to endorse normalizing causes. In the 12 months following their initial visit, somatizers made less use of speciality mental health care and were less likely to present emotional problems to their GP. Somatizers were markedly less likely to talk about personal problems to their GP and reported themselves less likely to seek help for anxiety or sadness. Somatization represents a persistent pattern of illness behaviour in which mental health care is not sought despite easily elicited evidence of emotional distress. Somatization is not, however, associated with higher levels of medical health care utilization than that found among patients with frank depression or anxiety.

Physician characteristics and the recognition of depression and anxiety in primary care.

We examined physician characteristics associated with the recognition of depression and anxiety in primary care. Fifty-five physicians treating a total of 600 patients completed measures of psychosocial orientation, psychological mindedness, self-rating of sensitivity to hidden emotions, and a video test of sensitivity to nonverbal communication. Patients were classified as cases of psychiatric distress based on the CES-D scale and the Diagnostic Interview Schedule. Physician recognition was determined by notation of any psychosocial diagnosis in the medical charts over the ensuing 12 months. Of 192 patients scoring 16 or above on the CES-D, 44% (83) were recognized as psychiatrically distressed. Three findings were central to this study: 1) Physicians who are more sensitive to nonverbal expressions of emotion made more psychiatric or psychosocial assessment of their patients and appeared to be over-inclusive in their judgments of psychosocial problems; 2) Physicians who tended to blame depressed patients for causing, exaggerating, or prolonging their depression made fewer psychosocial assessments and were less accurate in detecting psychiatric distress; 3) False positive labeling of patients who had no evidence of psychiatric distress was rare. Surprisingly, more severe medical illness increased the likelihood of labeling and accurate recognition. Physician factors that increased recognition may indicate a greater willingness to formulate a psychiatric diagnosis and an ability notice nonverbal signs of distress.

Latent Variable Models of Functional Somatic Distress

Latent variable models of functional somatic symptoms were estimated for a sample of 686 family medicine patients. Symptom items from the NIMH Diagnostic Interview Schedule were selected to approximate diagnoses of fibromyalgia syndrome (FMS), chronic fatigue syndrome (CFS), and irritable bowel syndrome (IBS). Confirmatory factor analysis demonstrated that hypothesized latent variables of somatic depression, somatic anxiety, FM-like, CF-like, and IB-like syndromes fit the observed covariations better than models hypothesizing fewer latent variables. Results offer tentative confirmation of functional somatic syndromes as discrete entities and suggest that relaxing the diagnostic criteria for somatization may identify individuals with distress limited to a single functional system.

Transient and persistent hypochondriacal worry in primary care

We present a 12-month prospective study of hypochondriacal worry in primary care. Data were obtained from 546 family medicine patients at the time of a physician visit for a new illness and again 1 year later. Patients were divided into four groups based on scores on the Illness Worry Scale: non-hypochondriacal (N = 460), transient hypochondriacal (N = 34); emerging hypochondriacal (N = 21); and persistent hypochondriacal (N = 31). Persistent patients had significantly more serious medical history but no more serious current illness than those low on illness worry. Patients with persistent illness worry were more likely than others to have a diagnosis of major depression or anxiety disorder, were more likely to believe that their most important significant other would pathologize new symptoms, yet were less likely to have been encouraged to see the doctor by them. Patients who became less worried over the year reported corresponding decreases in distress, attentiveness to bodily sensations, emotional vulnerability and pathological symptom attributions. We conclude that depressive or anxiety disorders, fears of emotional instability, pathological symptom attributional styles and interpersonal vulnerability provide the best prognostic evidence for enduring illness worry.

Cognitive and Social Correlates of the Toronto Alexithymia Scale

The authors examine the relationship of the Toronto Alexithymia Scale (TAS) to sociodemographic characteristics, medical history, symptomatology, and illness cognition in a sample of 244 family medicine patients. The TAS had moderate internal reliability. In multiple regression analysis, the TAS was related to age, education, depressive symptoms, emotion suppression, self-consciousness, illness worry, and tendency to attribute somatic symptoms to psychological causes. Factor analysis of the TAS yielded four factors: Factor 1 (difficulty identifying feelings and bodily sensations) was related to education, social desirability, depressive symptoms, and private body-consciousness. Factor 2 (externally oriented thinking) was related to emotion suppression and self-consciousness. Factor 3 (difficulty expressing feelings to others) was related to age, social desirability, severity of past medical illness, depressive and somatic symptoms, and emotion suppression. Factor 4 (reduced daydreaming) was related to age and self-consciousness. The TAS measures conceptually distinct dimensions that are best studied as separate factors in psychosomatic models.

Support from significant others and loneliness following induced abortion

SummaryThe relationship between support from significant others and feelings of loneliness 1 week after induced abortion was investigated. Support from the male partner before, during, and after the procedure was shown to be related to less frequent feelings of loneliness among 228 abortion recipients. Involvement or support of parents before and during the procedure had no effect on loneliness. Women whose relationship with their mothers became closer after the abortion, however, were less likely to feel lonely. Results are discussed in terms of the sharing of responsibilities in pregnancy and abortion that is consistent with the meaning of social support.

Out-of-Wedlock Abortion and Delivery: The Importance of The Male Partner

When a single pregnant woman has an abortion, it is often assumed that her relationship to her male partner will break up, either before the abortion or afterwards. This study compares the relationships of 139 single women who had abortions with those of 109 single women who chose to have their babies. Women who abort, while less strongly tied to their partners before becoming pregnant, are no more likely to end their relationships six weeks or one year after the abortion than are women who deliver. However, abortion recipients who have strong, loving relationships with their partners after the abortion experience greater adverse emotional reactions and dissatisfaction with their abortion than do abortion recipients with weaker relationships. Compared with single women who choose not to abort, the forces acting to separate an abortion recipient from her partner are present before pregnancy and abortion, and not necessarily triggered by the experience. A loving relationship may increase a single womans ambivalence about having an abortion.