Is somatosensory amplification a risk factor for an increased report of side effects? Reference data from the German general population

OBJECTIVE

The study investigates the association between somatosensory amplification and the reporting of side effects. It establishes a German version of the Somatosensory Amplification Scale and examines its psychometric properties in a representative sample of the German population.

METHODS

Sample size was 2.469, with 51% taking any medication. Participants answered the Somatosensory Amplification Scale, Generic Assessment of Side Effects Scale, and indicated whether they were taking any medication and the type of medication. Correlational analysis and binary logistic regression were performed.

RESULTS

When examining a subsample reporting both medication intake and general bodily symptoms, participants higher in somatosensory amplification rated more of their general bodily symptoms as medication-attributed side effects. However, somatosensory amplification scores were not associated with the intake of any type of medication. In the overall sample, higher somatosensory amplification scores were associated with an increased report of bodily symptoms. Additionally, participants with higher somatosensory amplification reported intake of a greater number of different medications. The psychometric properties of the translated scale were good, and previously established associations of somatosensory amplification with demographic variables (age, sex) were replicated.

CONCLUSION

Results suggest a possible attributional bias concomitant to somatosensory amplification which in turn may increase the reporting of side effects after medication intake.

Somatization and symptom reduction through a behavioral medicine intervention in a mind/body medicine clinic

The authors assessed data from 1,148 outpatients in a 10-week medical symptom reduction program to determine the effectiveness of a behavioral medicine intervention among somatizing patients. The program included instruction in the relaxation response, cognitive restructuring, nutrition, and exercise. Before and after the intervention, the patients were evaluated on the Symptom Checklist-90 Revised (SCL-90R), the Medical Symptom Checklist, and the Stress Perception Scale. They were divided into high- and low-somatizing groups on the basis of the pretreatment SCL-90R somatization scale. At the end of the program, physical and psychological symptoms on the Medical Symptom Checklist and the SCL-90R were significantly reduced in both groups, with the reductions greater in the high-somatizing group. Improvements in stress perception were about the same in both groups, but the absence of an untreated control group precluded estimates of how much the improvements resulted from the behavioral medicine intervention and how much from natural healing over time.

Depression and education as predicting factors for completion of a behavioral medicine intervention in a mind/body medicine clinic

The authors compared characteristics of 1,012 outpatients completing a 10-week behavioral medicine intervention with 300 outpatients who dropped out. They administered the Symptom Checklist-90 Revised (SCL-90R) before and after the program. Patients who completed the treatment, compared with dropouts, tended to be more highly educated, married, and gainfully employed. Their pretreatment scores on the SCL-90R were significantly lower than those of the dropouts on somatization, depression, and obsessive-compulsive scales and on the global severity index. Multiple logistic regression analysis indicated that lower depression and higher education marked the group who completed the intervention in contrast to the dropouts. After the intervention, all of the SCL-90R scores were significantly lower among patients who completed the treatment. Pre- to postintervention score changes were not significantly associated with the number of sessions attended. The findings suggest that the intervention had salutary effects in patients with mind/body distress and that its effectiveness was not diminished by a few absences. Depressed or less educated patients might benefit from preparatory interventions or from a modified approach to their treatment.

Effects of gender and marital status on somatic symptoms of patients attending a mind/body medicine clinic

To clarify the mechanisms of gender-related mind/body relationships, the authors analyzed the characteristics of 1,132 outpatients (848 women and 284 men) attending a mind/body medicine clinic. At entry in the program, the patients completed the Medical Symptom Checklist, Symptom Checklist-90 revised (SCL-90R), and Stress Perception Scale. Women reported 9 out of 12 symptoms (fatigue, insomnia, headache, back pain, joint or limb pain, palpitations, constipation, nausea, and dizziness) more frequently than the men did. Being a woman was a predictor of the total number of somatic symptoms endorsed. SCL-90R somatization scores were significantly higher in nonmarried women than in married women. Perceived stress ratings of family and health were higher in women than in men, despite the lower degree of perceived stress concerning work. Women, especially nonmarried women, were more likely to report somatic discomfort. Gender appears to be an important factor in relation to the report of somatic symptoms in stress-related conditions.

Somatic symptom reporting in women and men

Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

Resource utilization of patients with hypochondriacal health anxiety and somatization

OBJECTIVES

To examine the resource utilization of patients with high levels of somatization and health-related anxiety.

DESIGN

Consecutive patients on randomly chosen days completed a self-report questionnaire assessing somatization and health-related, hypochondriacal anxiety. Their medical care utilization in the year preceding and following completion of the questionnaire was obtained from an automated patient record. The utilization of patients above and below a predetermined threshold on the questionnaire was then compared.

PATIENTS AND SETTING

Eight hundred seventy-six patients attending a primary care clinic in a large, urban, teaching hospital.

OUTCOME MEASURES

Number of ambulatory physician visits (primary care and specialist), outpatient costs (total, physician services, and laboratory procedures), proportion of patients hospitalized, and proportion of patients receiving emergency care.

RESULTS

Patients in the uppermost 14% of the clinic population on somatization and hypochondriacal health anxiety had appreciably and significantly higher utilization in the year preceding and the year following completion of the somatization questionnaire than did the rest of the patients in the clinic. After adjusting for group differences in sociodemographic characteristics and medical comorbidity, significant differences in utilization remained. In the year preceding the assessment of somatization, their adjusted total outpatient costs were $1,312 (95% CI $1154, $1481) versus $954 (95% CI $868, $1057) for the remainder of the patients and the total number of physician visits was 9.21 (95% CI 7.94, 10.40) versus 6.33 (95% CI 5.87, 6.90). In the year following the assessment of somatization, those above the threshold had adjusted total outpatient costs of $1,395 (95% CI $1243, $1586) versus $1,145 (95% CI $1038, $1282), 9.8 total physician visits (95% CI 8.66, 11.07) versus 7.2 (95% CI 6.62, 7.77), and had a 24% (95% CI 19%, 30%) versus 17% (95% CI 14%, 20%) chance of being hospitalized.

CONCLUSIONS

Primary care patients who somatize and have high levels of health-related anxiety have considerably higher medical care utilization than nonsomatizers in the year before and after being assessed. This differential persists after adjusting for differences in sociodemographic characteristics and medical morbidity.

Hypochondriacal patients' appraisal of health and physical risks

OBJECTIVE

The authors' goal was to assess the degree to which hypochondriasis is accompanied by a heightened sense of risk of disease and other physical hazards.

METHOD

Fifty-six patients meeting DSM-III-R criteria for hypochondriasis were compared with 127 nonhypochondriacal patients from the same primary care setting. Both groups completed a self-report questionnaire assessing the degree to which they felt at risk of developing various medical diseases or being subject to injury from accidents or criminal assault.

RESULTS

Both groups of patients exhibited an optimistic bias in that they considered themselves to be less at risk than others of their age and sex. However, the hypochondriacal group had a significantly higher total risk score than did the nonhypochondriacal group. In large part, this intergroup difference was the result of the hypochondriacal patients' perception that they were likely to develop various diseases. The hypochondriacal group did not score significantly higher than the comparison group in estimating their risk of succumbing to accidents and criminal victimization. Perceived risk was significantly associated with the self-reported tendency to amplify benign bodily sensations.

CONCLUSIONS

An exaggerated appraisal of risk, jeopardy, and vulnerability to disease may be part of the cognitive distortion seen in hypochondriasis. If this is confirmed, cognitive and behavioral therapies for hypochondriasis may need to include a focus on these patients' understanding and appraisal of risk.

Palpitations, arrhythmias, and awareness of cardiac activity

Somatic and visceral symptoms have a surprisingly weak relationship to objective measures of tissue pathology. This is exemplified by the poor correlation found between palpitations and cardiac arrhythmias. Many factors other than extent of disease influence symptomatic distress, and since symptoms are such a crucial feature of illness and of medical practice, much more investigation of these nonbiomedical influences is needed. Although experimental laboratory paradigms facilitate such investigation, there are problems involved in generalizing from laboratory findings to the reporting of the symptoms of disease in daily life. In studying the awareness of cardiac arrhythmias and of resting heartbeat, we have found that the palpitations of patients who somatize more and have more health-related anxiety and more psychiatric distress are significantly less likely to be related to demonstrable cardiac arrhythmias than are the palpitations of other patients. The accurate awareness of arrhythmias, however, is not associated with the accurate awareness of resting heartbeat. Even more surprising, a relatively large proportion of heart transplant recipients are accurately aware of their resting heartbeat. This work poses more questions than it answers. In so doing, it underscores some of the technical difficulties of conducting research in this area and shows how little is known about symptom perception, processing, and reporting.

Somatic symptom reporting in women and men

Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

Correlation between somatic sensation inventory scores and hyperarousal scale scores

Somatization mechanisms are poorly understood. The authors tested whether somatization might involve altered central nervous system information processing. They measured somatization using the Somatization Sensation Inventory (SSI) and information processing style using the Hyperarousal Scale, scores of which correlate with electroencephalogram(EEG) measures of cortical electrical responsiveness. SSI scores correlated highly with Hyperarousal scores. On logistic regression, two SSI items and two Hyperarousal items accounted for most of this correlation. These specific hyperarousal items had previously been found to covary with EEG activity and cortical evoked potential amplitudes. The authors concluded that somatization may involve altered CNS processing of somatic stimuli.

Anxiety is a good indicator for somatic symptom reduction through behavioral medicine intervention in a mind/body medicine clinic

BACKGROUND

This study examined the effect of anxiety on symptom reduction through a behavioral medicine intervention in a Mind/Body Medicine Clinic.

METHOD

Participants were 1,312 outpatients attending a 10-week behavioral medicine intervention which included training in the relaxation response, cognitive restructuring, exercise and nutrition. All of the patients had physical symptoms and were referred to the clinic by their physician. The Medical Symptom Checklist (12 major symptoms), Symptom Checklist 90 Revised (SCL-90R), Stress Perception Scale and the Health-Promoting Lifestyle Profile were administered before and after the program.

RESULTS

Of the sample, 1,012 patients completed the program, and 911 completed the posttreatment assessment. Self-reported frequency of medical symptoms, degree of discomfort and interference with daily activities were significantly reduced as a result of the program. Anxiety and other psychological distress as measured by the SCL-90R and stress perception scales also showed significant reductions. Furthermore, health-promoting lifestyle functioning significantly improved. High levels of pretreatment anxiety predicted a decrease in the total number of medical symptoms endorsed.

CONCLUSIONS

Behavioral medicine interventions are effective in reducing medical symptoms coinciding with improvement in anxiety. High anxiety at program entry may predict better outcome.

Psychiatric symptoms and medical utilization in primary care patients

In two studies, the authors evaluated the impact of psychiatric disorders on medical care utilization in a primary care setting. In the first study, 526 consecutive patients in a teaching hospital primary care practice completed the 18-item RAND Mental Health Inventory to identify clinically significant depression and/or anxiety and a questionnaire about the use of psychiatric treatment and psychoactive medications. The medical utilization of those patients defined as depressed and/ or anxious was compared with those defined as not depressed and/or anxious. Patients identified as depressed and/or anxious reported significantly increased medical utilization, but this was not confirmed by the hospital's computerized record system. In the second study, the authors analyzed medical care utilization for the years before and after the first outpatient psychiatry appointment of a sample of 91 patients referred from the same primary care practice to the hospital's outpatient psychiatry clinic over a 1-year period. In both studies there was not a statistically significant difference in medical utilization among those patients receiving psychiatric treatment. The findings demonstrate the difficulties in examining cost offset in a primary care population and raise questions about it as a realistic outcome measure of the effect of psychiatric treatment.

Predictors of remission in DSM hypochondriasis

Although hypochondriasis is generally believed to be a chronic and refractory disorder, relatively little is known about its natural history and course. Based on a cognitive/perceptual model of hypochondriasis, we hypothesized that the disorder would be more chronic in patients who both amplify benign bodily symptoms and tend to attribute them to disease. Thirty-eight patients with DSM hypochondriasis were assessed with a structured, diagnostic interview and self-report questionnaire. A logistic regression model containing sociodemographic characteristics and a 3-way interaction term composed of the tendency to amplify bodily sensations, the tendency to attribute common symptoms to disease, and somatization (all measured at inception) correctly classified the remission status of 81.6% of the patients at follow-up 4 years later. These results suggest that patients who somatize, who are amplifiers of bodily sensation, and those who tend to attribute ambiguous symptoms to disease have more chronic and more refractory hypochondriasis. It is the co-occurrence of these cognitive and perceptual characteristics, rather than their occurrence individually, which predicts the persistence of this disorder.

Heartbeat perception in panic disorder: a reanalysis

This article describes a reanalysis of seven studies on heart beat perception (HBP) in panic disorder. The pooled sample had 709 participants from eight diagnostic categories. Accurate HBP was uncommon, but more prevalent among panic disorder patients than among healthy controls, depressed patients, patients with palpitations and individuals with infrequent panic attacks. No differences were found between panic disorder patients and patients with other anxiety disorders. Accurate perceivers had higher anxiety sensitivity scores than inaccurate perceivers. The data remain inconclusive as to whether perceived heart rate is correlated with anxiety in inaccurate perceivers. Physical exercise, distraction, variations in instructions and treatment each influenced HBP. However, the influence was different than previously thought. Finally, it is suggested that HBP may be understood in terms of schema-guided information processing.

Somatic style and symptom reporting in rheumatoid arthritis

The authors studied the relative contributions of psychological characteristics and rheumatoid arthritis (RA) morbidity to RA symptoms and medication side effects. Thirty-one consecutive patients attending an RA clinic completed self-report questionnaires and diaries assessing RA symptoms and somatic style, a constellation of beliefs, attitudes, and concerns about disease and health. After 3 months, the patients were assessed for RA symptoms and self-reported medication side effects. At inception, RA symptoms were associated with several components of somatic style. At 3-month follow-up, changes in RA symptoms and the incidence of medication side effects were predicted by somatic style variables measured at inception. The symptoms of RA and the side effects of RA pharmacotherapy are prospectively predicted by somatic style as well as by the severity and extent of RA.

Perceptual and memory biases for health-related information in hypochondriacal individuals

Problematic health concerns characteristic of hypochondriasis may be better understood with the aid of cognitive, information processing theories. We investigated whether hypochondriacal individuals show perceptual and explicit memory biases favoring health-related information. A clinical sample of hypochondriacs (n=18) and healthy controls (n=22), and a sample of hypochondriacal (n=22) and nonhypochondriacal (n=67) patients referred for Holter monitoring, completed a computerized test of perceiving difficult-to-read words and then an encoding task followed by recall of those words. Contrary to our prediction, hypochondriacal individuals in the clinical sample did not perceive more health-related words than words not related to health. Hypochondriacal individuals in the Holter-monitoring sample showed an unexpected bias against reporting health-related words. Social class may account for some of the group differences in this sample. Hypochondriacal individuals in both samples showed better memory for health-related than nonhealth words.

Functional somatic syndromes

The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one's condition is likely to worsen; the "sick role," including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.

Panic disorder patients and their medical care

The goal of the study was to examine the functional status and medical care of general medical outpatients with panic disorder. One hundred patients completed self-report questionnaires and a diagnostic interview for panic disorder. They were compared with a random sample of patients without panic disorder. Medical morbidity was assessed from the medical record, and the patients' clinic physicians completed a questionnaire about them. The prevalence of current (1 month) panic disorder was 6.7%-8.3%. The panic disorder patients had fewer serious medical diagnoses, but more medical utilization and more role impairment than the comparison group. The clinic physicians rated the panic patients as more anxious, more depressed, more hypochondriacal, and more difficult to care for. Sixty-one percent of the panic disorder patients recalled receiving an anxiety disorder diagnosis. These findings add to a growing body of evidence that panic disorder imposes a significant burden on those with this illness and that it is a seriously underdiagnosed condition in primary care practice.

Palpitations and cardiac awareness after heart transplantation

OBJECTIVE

The aim of this study was to examine the awareness of resting heartbeat in heart transplantation recipients, compare it with that found in other medical populations, and determine whether clinical characteristics are associated with accurate heartbeat awareness.

METHODS

Eligible patients underwent a research battery consisting of a heartbeat detection task and self-report questionnaires assessing cardiac symptoms, psychosocial variables, and cognitive function. The accurate awareness of resting heartbeat was determined by presenting the patients with auditory stimuli at each of six different delays following the R wave on the ECG. Patients then selected the tones that they thought coincided with the sensation they had of their heart beating. The patients' physicians rated their cardiac morbidity. The results were contrasted with comparable data obtained in previous work with other ambulatory medical populations.

RESULTS

Forty-one consecutive heart transplantation recipients who survived for at least 3 months after surgery were eligible. Thirty-four (82.9%) of them were studied and complete data were obtained on 26 (63.4%). Nine patients (34.6%) were reliably able to detect their resting heartbeat. When compared with the 17 patients who were not accurately aware of their heartbeat, the two groups did not differ significantly in cardiac morbidity, cognitive brain dysfunction, generalized psychiatric distress, depression, somatization, or hypochondriacal attitudes. A significantly higher proportion of heart transplantation recipients were accurately aware of their heartbeat than was found in a sample of general medical outpatients and in asymptomatic, nonpatient volunteers.

CONCLUSIONS

One-third of heart transplant recipients are accurately aware of resting heartbeat, despite the absence of cardiac innervation.

Cardiorespiratory symptoms in response to physiological arousal

OBJECTIVE

To develop a laboratory paradigm for assessing the tendency to amplify somatic symptoms and report bodily distress.

METHOD

Reports of four different cardiopulmonary symptoms were obtained during standardized, treadmill exercise, while the physiological parameters which induce these symptoms were simultaneously measured. Two indices were developed to compare symptom reporting across patients: symptom severity after reaching 80% of predicted, maximal exercise capacity; and the magnitude of physiological arousal necessary to induce an initial sensation of discomfort.

RESULTS

Fifty-one medical outpatients with a chief complaint of palpitations were studied. Symptom distress at 80% of maximal exercise capacity was significantly associated with state anxiety and daily life stress. The complaint of "heart racing" first occurred at a significantly lower heart rate for patients who were older, more anxious, and reported more daily life stress. Measures of hypochondriasis, somatization, bodily amplification, and bodily absorption were not significantly associated with either symptom measure.

CONCLUSIONS

Standardized exercise testing may provide a suitable paradigm with which to study the tendency to amplify symptoms and to somatize. The distress reported by different subjects at 80% of maximal exercise capacity may be considered an index of the discomfort engendered by a standardized stimulus, whereas the point of onset of discomfort may be a measure of the patient's threshold for becoming symptomatic. These findings are not conclusive, but do suggest that patients who are more anxious and under more stress tend to report more intense cardiopulmonary symptoms at comparable levels of physiological arousal, and to have a lower threshold for experiencing discomfort.

A prospective 4- to 5-year study of DSM-III-R hypochondriasis

BACKGROUND

Although hypochondriasis is generally thought to be a chronic and stable condition with a relatively low remission rate, this disorder remains understudied.

METHODS

This is a 4- to 5-year prospective case-control study of DSM-III-R hypochondriasis. Medical outpatients meeting DSM diagnostic criteria for hypochondriasis completed an extensive research battery assessing hypochondriacal symptoms, medical and psychiatric comorbidity, functional status and role impairment, and medical care. A comparison group of nonhypochondriacal patients from the same setting underwent the same battery. Four to 5 years later, both cohorts were re-interviewed.

RESULTS

One hundred twenty hypochondriacal and 133 nonhypochondriacal comparison patients were originally studied. Follow-up was obtained on 73.5% (n = 186) of all patients. At follow-up, the hypochondriacal sample was significantly (P<.001) less hypochondriacal and had less somatization (P<.001) and disability than at inception, but 63.5% (n = 54) still met DSM-III-R diagnostic criteria. When compared with the comparison group using repeated measures multivariate analysis of variance, these changes remained statistically significant (P<.0001). Changes in medical and psychiatric comorbidity did not differ between the 2 groups. When hypochondriacal patients who did and did not meet diagnostic criteria at follow-up were compared, the latter had significantly less disease conviction (P<.05) and somatization (P<.01) at inception, and their incidence of major medical illness during the follow-up period was significantly (P<.05) greater.

CONCLUSIONS

Hypochondriacal patients show a considerable decline in symptoms and improvement in role functioning over 4 to 5 years but two thirds of them still meet diagnostic criteria. Hypochondriasis, therefore, carries a very substantial, long-term burden of morbidity, functional impairment, and personal distress.

Differential diagnosis of palpitations. Preliminary development of a screening instrument

OBJECTIVE

To develop a self-report screening instrument to assist in the differential diagnosis of medical outpatients complaining of palpitations.

DESIGN

Patients completed self-report questionnaires assessing somatization, cardiac symptoms, and hypochondriacal concerns about health. Principal components analysis was performed to identify a subset of questions that could be used to distinguish patients with palpitations who have panic disorder from those with palpitations who do not have panic disorder.

PATIENTS

Sixty-seven medical outpatients referred for Holter monitoring because of a complaint of palpitations.

MAIN OUTCOME MEASURES

Patients with palpitations were classified into 2 groups, those with and those without current panic disorder (established with a structured, diagnostic interview). The sensitivity, specificity, and posttest probability of the screening instrument were determined.

RESULTS

A reliable, stable, 10-item instrument was derived. It seems to tap diffuse, vague, or generalized somatic complaints and worry about physical illness. With the use of a criterion cutoff score of 21, this instrument had a sensitivity of 0.81, a specificity of 0.80, and a post-test probability of.57 in detecting current panic disorder in patients with palpitations.

CONCLUSIONS

A psychometrically sound and brief self-report instrument was developed to assist in the differential diagnosis of palpitations. It can be used to identify patients whose symptoms are more likely to result from panic disorder and in whom ambulatory monitoring might be deferred.

Somatized psychiatric disorder presenting as palpitations

BACKGROUND

Psychiatric disorder is underdiagnosed in primary care practice, often because it is somatized and the patient reports only physical symptoms. Palpitations are among the symptoms that often are somatized.

METHODS

We studied prospectively 125 consecutive medical outpatients referred for ambulatory electrocardiographic monitoring to evaluate a chief complaint of palpitations. They completed an in-person research interview at the time of monitoring and a telephone follow-up interview 3 months later. The referring physicians completed questionnaires about their patients before receiving the results of the monitoring and again 3 months later.

RESULTS

Forty-three patients had clinically significant cardiac arrhythmias. Twenty-four (29%) of the remaining 82 patients had a current psychiatric disorder, and 20 of these patients (83%) had major depression or panic disorder. These patients were significantly younger and more disabled, somatized more, and had more hypochondriacal concerns about their health than did patients who had no psychiatric disorder. Their palpitations were more likely to last longer than 15 minutes, were accompanied by more ancillary symptoms, and were described as more intense. At 3-month follow-up, about 90% of the patients in both groups continued to experience palpitations. Symptoms of somatization, hypochondriacal concerns, and impairment of intermediate activities had improved in both groups, but remained higher in patients with psychiatric disorder than in patients without psychiatric disorder. During the follow-up interval, patients with psychiatric disorder had more emergency department visits. The physicians of patients with psychiatric disorder were more likely to ascribe the palpitations to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatment were referred or started on psychotropic medication.

CONCLUSIONS

Physicians are aware of a psychiatric component to the clinical presentation of palpitation, but this observation does not result in psychiatric treatment or referral in most cases.

Predictors of persistent palpitations and continued medical utilization

BACKGROUND

The aim of this study was to determine the predictors of persistent palpitations and continued medical utilization in a sample of medical patients referred for ambulatory electrocardiographic monitoring.

METHODS

A prospective telephone follow-up was conducted with patients who had undergone ambulatory electrocardiographic monitoring 3 months earlier. At inception, patients completed in-person interviews and self-report questionnaires, assessing somatization, hypochondriacal attitudes, bodily amplification (high degree of sensitivity to bodily sensations), and two types of life stress (minor daily irritants and major life changes). At follow-up, patients completed a structured interview about their clinical course, palpitations, and utilization of medical care during the interval.

RESULTS

At 3-month follow-up, 55 of the inception cohort of 67 patients were interviewed again. The mean severity of palpitations for the entire sample declined significantly, but 46 (83.6%) patients continued to experience their presenting symptoms. Stepwise multiple linear regression revealed that the interaction of bodily amplification and daily life stress at inception uniquely explained 10.0% of the variance in palpitation severity at follow-up. A four-step model composed of these two interaction terms and age and education level accounted for 21.4% of the variance in palpitations. The medical utilization findings are complementary in that the interaction of amplification and daily irritants at baseline predicted the number of unscheduled medical visits over the subsequent 3 months. The total number of ventricular premature contractions occurring during ambulatory monitoring was not a significant predictor of palpitations.

CONCLUSIONS

Palpitations are more persistent in persons who are both highly sensitive to bodily sensations and who experience a greater number of minor daily irritants. The existence of either predictor alone is not sufficient to perpetrate this functional somatic symptom; it requires the combination of these predictors.

Hypochondriasis. Medical management and psychiatric treatment

This study describes a 2-part approach to the hypochondriacal patient: 1) a strategy for medical management, and 2) a specific psychiatric therapy. Medical management rests on the physician's recognition that patients have psychological and interpersonal reasons for feeling symptomatic and seeking medical attention. After gaining this appreciation, the physician can stop trying to cure the patient's symptoms, and the goal of management then shifts to assisting the patient in coping with the symptoms. A specific psychotherapy is then presented. Group discussions and cognitive and behavioral exercises are used to teach patients to moderate four factors that amplify somatic distress and hypochondriacal health concerns: the attention they pay to their symptoms, their thoughts about them, the context in which they experience their symptoms, and their moods.

Somatization and medicalization in the era of managed care

Somatization, the reporting of somatic symptoms that have no pathophysiological explanation, appears to be increasing as sociocultural currents reduce the public's tolerance of mild symptoms and benign infirmities and lower the threshold for seeking medical attention for such complaints. These trends coincide with a progressive medicalization of physical distress in which uncomfortable bodily states and isolated symptoms are reclassified as diseases for which medical treatment is sought. Somatization and medicalization are likely to become more problematic in the era of managed care. Under capitation, providers will have greater incentives to reduce utilization, and somatizing patients may feel forced to express their "disease" in more urgent and exaggerated terms in order to gain access to the physician. In addition, prepaid subscribers will suffer little financial disincentive to seek medical attention for relatively minor complaints; therefore, they are likely to increase the demand for physician consultation. This situation suggests an urgent need to improve the management of somatizing patients. Innovative consultative, behavioral, and educational interventions are now available. In addition, medical professionals should greet the process of medicalization with considerable caution and educate the public more about the normative presence of symptoms and bodily distress in healthy people. Additional research is needed into somatization and its relationship to the demand for medical care. In an era of managed care, increased attention should be devoted to understanding and controlling the demand for care, a large portion of which is symptom driven.

The clinical course of palpitations in medical outpatients

OBJECTIVE

The aim of this study was to describe the longitudinal course of patients who were referred for ambulatory electrocardiographic monitoring because of palpitations.

METHODS

A prospective, follow-up examination was conducted of patients who had been studied 6 months previously when referred for monitoring. The inception cohort consisted of 145 consecutive patients with palpitations and 70 asymptomatic, nonpatient volunteers. At follow-up, the patients completed the same research battery as at inception, consisting of structured interviews and self-report questionnaires. These assessed cardiac symptoms, medical care use, role impairment, somatization, hypochondriacal fears and beliefs, and psychiatric disorder.

RESULTS

At 6 months' follow-up, 130 patients with palpitations (89.7% of the original cohort) and 69 nonpatients (98.6%) were reinterviewed. Eighty-four percent of the patients had recurrent palpitations during the 6-month follow-up period. At follow-up, patients with palpitations scored significantly higher than the comparison group on measures of cardiac symptoms and role impairment, and had made more physician visits in the preceding 6 months. They had a higher prevalence of panic disorder and more psychopathologic symptoms, somatized more, and were more hypochondriacal. Psychiatric symptoms and the tendency to amplify bodily sensation, measured at inception, were significant but modest predictors of subsequent palpitations. There was considerable confusion and misunderstanding among patients as to the findings of their ambulatory electrocardiogram and the presence or absence of panic disorder.

CONCLUSIONS

Patients with palpitations remain symptomatic and functionally impaired and have increased rates of physician visits in the 6 months following Holter monitoring. They also continue to have elevated rates of panic disorder and to evidence some confusion about the cause of their symptoms.

Accurate awareness of heartbeat in hypochondriacal and non-hypochondriacal patients

We measured the accurate awareness of resting heartbeat in a sample of medical out-patients meeting DSM-III-R criteria for hypochondriasis (n = 60), and in a comparison group of non-hypochondriacal patients (n = 60) from the same general medical clinic. Patients also completed subjective self-report ratings of their sensitivity to benign bodily sensation and of functional somatic symptoms. Hypochondriacal patients did not differ significantly from non-hypochondriacal patients in their accurate awareness of heartbeat. They did, however, consider themselves more sensitive to benign bodily sensation and report more functional somatic symptoms. Within each sample, the only statistically significant association found was a negative correlation (r = -0.32, p = 0.025) between heartbeat awareness and the severity of hypochondriacal symptoms among the hypochondriacal patients. These results suggest that hypochondriacs may not be more accurately aware of normal cardiac activity, and therefore that hypochondriacal somatic complaints may not result from an unusually fine discriminative ability to detect normal physiological sensations that non-hypochondriacal individuals do not perceive.

Hypochondriasis and panic disorder. Boundary and overlap

BACKGROUND

To determine the nosological and phenomenological overlap and boundaries between panic disorder and hypochondriasis, we compared the symptoms, disability, comorbidity, and medical care of primary care patients with each diagnosis.

METHODS

Patients with DSM-III-R panic disorder were recruited by screening consecutive primary care clinic attenders and then administering a structured diagnostic interview for panic disorder. Patients also completed self-report questionnaires, and their primary care physicians completed questionnaires about them. They were then compared with patients with DSM-III-R hypochondriasis from the same setting who had been studied previously.

RESULTS

One thousand six hundred thirty-four patients were screened; 135 (71.0% of the 190 eligible patients) completed the research battery; 100 met lifetime panic disorder criteria. Twenty-five of these had comorbid hypochondriasis. Those without comorbid hypochondriasis (n = 75) were then compared with patients with hypochondriasis without comorbid panic disorder (n = 51). Patients with panic disorder were less hypochondriacal (P < .001), somatized less (P < .05), were less disabled (P < .001), were more satisfied with their medical care (P < .001), and were rated by their physicians as less help rejecting (P < .05) and less demanding (P < .01). Major depression was more prevalent in the group with panic disorder (66.7% vs 45.1%; P < .05), as were phobias (76.0% vs 37.3%; P < .001), but somatization disorder symptoms (P < .0001) and generalized anxiety disorder were less prevalent (74.5% vs 16.0%; P < .001) in panic disorder than was hypochondriasis.

CONCLUSIONS

While hypochondriasis and panic disorder co-occur to some extent in a primary care population, the overlap is by no means complete. These patients are phenomenologically and functionally differentiable and distinct and are viewed differently by their primary care physicians.

Do women somatize more than men? Gender differences in somatization

Reviewing the literature of the latter half of the twentieth century, the authors consider the question: do women somatize more than men? The literature review begins with work done in the 1950s in order to look at the phenomenon of somatization as a constellation of symptoms. It encompasses work done in the general community and in the medical arena. The critique of the literature shows why the role of gender in somatizing remains unclear, elucidates inconsistencies, notes the confounding variables, and points out the degree of variable interaction and observer bias. Possible explanations or causes of gender differences are explored. In the present body of literature, women do somatize more than men; however, some of the studies in the literature are flawed. The changing gender difference in medical literature implies that the inquiry at hand concerns the etiology and expression of somatization itself.

The accuracy of symptom reporting by patients complaining of palpitations

PURPOSE

To examine the relationship between patients' reports of palpitations and documented arrhythmias.

PATIENTS AND METHODS

Consecutive patients complaining of palpitations and referred for 24-hour ambulatory electrocardiographic monitoring were studied using self-report questionnaires and a structured diagnostic interview. Electrocardiographic results were subsequently analyzed in conjunction with symptom diaries. Positive predictive value was used to estimate the likelihood that a reported symptom coincided with a documented arrhythmia. Sensitivity was calculated as a measure of the likelihood that an arrhythmia would be detected and reported as a symptom.

RESULTS

Positive predictive value was inversely related to somatization, hypochondriacal attitudes, and psychiatric symptoms. It was not related to chronicity of palpitations, previously diagnosed heart disease, more extensive medical care utilization, or clinically significant arrhythmias. Patients were generally insensitive to their arrhythmias, failing to note the vast majority.

CONCLUSIONS

Somatizing and hypochondriacal patients are not more sensitive to or accurately aware of subtle changes in cardiac activity, but rather may be expressing a response bias toward reporting somatic and psychologic distress in general. Apparently, patients do not learn to discriminate and detect cardiac activity more accurately as a result of having more medical care or suffering longer with their symptoms.

Psychiatric disorders in medical outpatients complaining of palpitations

OBJECTIVE

To determine the prevalence of psychiatric disorders in ambulatory patients undergoing Holter monitoring to evaluate palpitations.

DESIGN

Patients referred for 24-hour ambulatory electrocardiographic (ECG) monitoring were studied with a structured diagnostic interview and self-report questionnaires prior to monitoring.

SETTING

Holter laboratory of a large academic medical center.

PATIENTS AND OTHER PARTICIPANTS

One hundred forty-five consecutive patients complaining of palpitations and 70 asymptomatic non-patient volunteers.

OUTCOME MEASURES

DSM-III-R psychiatric diagnoses.

RESULTS

Forty-five percent (44.8%) of the participants had at least one lifetime anxiety or depressive disorder and 24.8% had at least one current (one month) disorder. The lifetime prevalence of panic disorder was 27.6%, and that of major depression was 20.8%. Current prevalence rates showed a similar pattern; the current prevalence of panic disorder was 18.6%. Panic disorder and somatization disorder symptoms were significantly more prevalent in the palpitation group than in the general medical clinic at the same hospital. Patients with a psychiatric diagnosis were more likely to report cardiac symptoms during monitoring than were those without psychiatric disorder, and more commonly described their symptoms as "pounding" and reported faintness, lightheadedness, and vertigo. Although cardiac histories and ECG results were no more serious, the patients with psychiatric diagnoses rated their overall health status as significantly worse.

CONCLUSIONS

Almost half of palpitation patients referred for Holter monitoring have a psychiatric disorder. More than a fourth have lifetime panic disorder and a fifth have had panic attacks in the month before monitoring.

Relationship between patient self-ratings and physician ratings of general health, depression, and anxiety

OBJECTIVE

To examine the relationship between patient self-ratings and physician ratings of general health, depression, and anxiety and patient and physician ratings in comparison to Diagnostic Interview Schedule (DIS) diagnoses of depression and anxiety.

DESIGN

Observational study.

SETTING

A general medical outpatient clinic.

PATIENTS

Clinic attendees.

METHOD

Consecutive clinic attendees on randomly selected days completed a self-reported screening questionnaire for hypochondriasis, composed of the Whiteley Index and the Somatic Symptom Inventory. A random sample of patients (N = 79), 95% of whom had scores below the cutoff for hypochondriasis (n = 75) and 5% of whom had scores at or above the cutoff for hypochondriasis (N = 4), returned at a later date to complete a research battery consisting of self-reported questionnaires, structured and semistructured interviews, and a structured interview for diagnoses of anxiety and depression based on the DIS, which used criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.

OUTCOME MEASURES

Responses to questionnaires and interviews.

RESULTS

Agreement between patients and physicians was statistically significant concerning patients' physical health, depression, and anxiety. Based on one question, both physicians' and patients' ratings of depression and anxiety compared favorably with DIS diagnoses. By means of receiver operating characteristics analysis, values for the areas under the curve and their SEs were as follows: for depression, 0.789 +/- 0.075 for patient self-ratings and 0.825 +/- 0.054 for physician ratings; for anxiety, 0.734 +/- 0.058 for patient self-ratings and 0.667 +/- 0.065 for physician ratings.

CONCLUSION

One simple question about a patient's status with respect to depression or anxiety is sufficient to detect these disorders with high sensitivity and specificity, yielding values comparable to those yielded by instruments consisting of many items. Asking patients to rate their own levels of depression and anxiety may constitute one portion of the family physician's diagnostic assessment for these conditions.

Histories of childhood trauma in adult hypochondriacal patients

OBJECTIVE

This study examined the childhood histories of trauma, parental attitudes toward health, and physical illness in hypochondriacal adults.

METHOD

Sixty outpatients with DSM-III-R hypochondriasis and 60 nonhypochondriacal outpatients from the same general medical clinic were compared. All patients completed the Childhood Traumatic Events Scale and an eight-item questionnaire about childhood illness and health. Medical morbidity was assessed with a medical record audit.

RESULTS

Significantly more hypochondriacal than nonhypochondriacal patients reported traumatic sexual contact (28.6% versus 7.3%), physical violence (32.1% versus 7.3%), and major parental upheaval (28.6% versus 9.1%) before the age of 17. These differences remained statistically significant after sociodemographic differences between the groups were controlled for with multivariate regression analysis. The two groups did not differ in the age at which these traumas occurred or in the degree of trauma experienced. Significantly more hypochondriacal patients reported being sick as children and missing school for health reasons, but they did not differ in other measures of childhood illness and parental attitudes toward illness. The two groups had similar levels of aggregate medical morbidity.

CONCLUSIONS

Hypochondriacal adults recall more childhood trauma than do nonhypochondriacal patients, even after sociodemographic differences are controlled for. They also recall more childhood illness, although they are not currently more medically sick.

Panic disorder, palpitations, and the awareness of cardiac activity

One hundred forty-five consecutive patients referred for ambulatory electrocardiographic monitoring for the evaluation of palpitations were studied just before monitoring. They were compared with 75 asymptomatic, nonpatient volunteers. The research battery included a structured diagnostic interview, self-report questionnaires, and perceptual tasks measuring awareness of cardiac activity. After monitoring, symptom reports were compared with concurrent electrocardiographic recordings to determine their accuracy. Forty palpitation patients (27.6%) had DSM-III-R lifetime panic disorder, and 27 (18.6%) had current (1-month) panic disorder. Panic patients were significantly more likely to describe their palpitations as "racing" or "pounding" and to have been awakened from sleep by them. They did not have more cardiac arrhythmias during 24-hour, electrocardiographic monitoring, and their symptom reports were significantly less likely to be due to demonstrable cardiac irregularities. They were not more accurately aware of resting heartbeat than nonpanic palpitation patients. They did score higher on self-report measures of somatization, hypochondriasis, and bodily amplification.

A research agenda for outpatient consultation-liaison psychiatry

Primary care settings are increasingly important sites for psychiatric research. A broader range of many psychiatric disorders is encountered here than in the mental health arena, and their study will therefore provide us with a more representative picture of the true nature of these disorders. This is also the setting in which to investigate the medical care process itself, including such phenomena as nonadherence with the medical regimen, patient delay before seeking appropriate medical attention, the placebo phenomenon, patient satisfaction, and the nature of the doctor-patient relationship. Much of primary care practice consists of the management and palliation of somatic symptoms, yet the phenomenology of somatic symptoms has barely been investigated. Outpatient psychiatric researchers are in an ideal position to study the entire process of symptom perception, formation, experience, and reporting, including the phenomenon of somatization. However, ambulatory medical settings impose particular constraints and demands upon consultation-liaison researchers. They may be met with indifference and even suspicion, and in turn they too often fail to appreciate the nature of the primary care setting and the research questions that are important to primary care providers, whose interest and involvement must be enlisted from the outset. Consultation-liaison researchers must acquire the substantive skills, knowledge, and techniques that are demanded by this type of research, because this work must be rigorous and of high caliber.

Hypochondriacal patients' beliefs about good health

OBJECTIVE

The authors hypothesized that hypochondriacal patients mistakenly believe good health to be a symptom-free state and that they consider more symptoms to be indicative of disease than do nonhypochondriacal patients.

METHOD

The Health Norms Sorting Task was developed to assess the standard used to decide whether one is sick or healthy; the respondent must classify 24 common and ambiguous symptoms as "healthy" or "not healthy." This instrument demonstrated good test-retest reliability and intrascale consistency. It was then administered to 60 patients with DSM-III-R hypochondriasis and 60 nonhypochondriacal patients randomly selected from the same general medicine clinic.

RESULTS

Hypochondriacal patients considered significantly more symptoms to be indicative of disease than did the comparison group. Health Norms Sorting Test scores were correlated with hypochondriacal symptoms, somatization, and self-reported bodily amplification (sensitivity to bodily sensation). Test scores were not related to aggregate medical morbidity, medical care utilization, or sociodemographic characteristics.

CONCLUSIONS

These data are compatible with the hypothesis that patients with DSM-III-R hypochondriasis believe good health to be relatively symptom free and consider more symptoms indicative of sickness. This may contribute to some of the clinical features of hypochondriasis, including the numerous somatic symptoms, bodily preoccupation, resistance to reassurance, and pursuit of medical care.

The course of transient hypochondriasis

OBJECTIVE

This study examined the longitudinal course of patients known to have had a previous episode of transient hypochondriasis.

METHOD

Twenty-two transiently hypochondriacal patients and 24 nonhypochondriacal patients from the same general medical clinic were reexamined after an average of 22 months with the use of self-report questionnaires, structured diagnostic interviews, and medical record review.

RESULTS

The hypochondriacal patients continued to manifest significantly more hypochondriacal symptoms, more somatization, and more psychopathological symptoms at follow-up. They also reported significantly more amplification of bodily sensations and more functional disability and utilized more medical care. These differences persisted after control for differences in medical morbidity and marital status. Only one hypochondriacal patient, however, had a DSM-III-R diagnosis of hypochondriasis at follow-up. Multivariate analyses revealed that the only significant predictors of hypochondriacal symptoms at follow-up were hypochondriacal symptoms and the tendency to amplify bodily sensations at the baseline evaluation.

CONCLUSIONS

Hypochondriacal symptoms appear to have some temporal stability: patients who experienced hypochondriacal episodes at the beginning of the study were significantly more hypochondriacal 2 years later than comparison patients. They were not, however, any more likely to develop DSM-III-R-defined hypochondriasis. Thus, hypochondriacal symptoms may be distinct from the axis I disorder. The data are also compatible with the hypothesis that preexisting amplification of bodily sensations is an important predictor of subsequent hypochondriacal symptoms.

The perception of cardiac activity in medical outpatients

This study compared several measures of cardiac perception and related them to patient' spontaneous reports of palpitations. One hundred and forty-five ambulatory patients referred for Holter monitoring for the evaluation of palpitations were compared with 70 asymptomatic nonpatients. Reports of palpitations during monitoring were compared with the ECG to determine whether they coincided with an arrhythmia. Subjects also completed a heartbeat detection task to determine whether they were accurately aware of cardiac systole while at rest. 20.7% of palpitation patients and 4.7% of asymptomatic controls demonstrated an accurate awareness of resting heartbeat (p = 0.01). Performance was unrelated to bodily amplification, somatization, hypochondriacal symptoms, ECG findings, or psychiatric morbidity. 34.3% of palpitation patients reported symptoms that consistently coincided with arrhythmias on ECG. These accurate patients had significantly lower levels of amplification, somatization, hypochondriacal symptoms, and psychiatric morbidity. Accuracy of symptom reporting and accuracy of heartbeat awareness were not statistically associated.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypochondriasis and obsessive compulsive disorder

Hypochondriasis and OCD differ conceptually in the degree to which the patient's disease concerns are experienced as an intrusive mental event or a reasonable psychological response to a realistic health threat, in the degree to which the ideation is resisted, and in the presence of somatic sensations and medical help-seeking. There are, however, some similarities between the conditions, including the development of excessive, stereotyped, repetitive behaviors in an attempt to allay their anxiety. Empirical data on the degree of overlap between the conditions are too limited to permit definitive conclusions. The little that we do know, however, suggests that (1) the prevalence of OCD in hypochondriasis is probably elevated, but not extraordinarily so; (2) the prevalence of hypochondriasis in OCD is unknown; (3) fears about disease, illness, and injury are one of the more common forms of obsessions seen in OCD; and (4) there are several ill-defined and largely unexplored conditions, such as disease phobias, which appear to be very similar to both OCD and hypochondriasis. Clinical experience suggests that there may be a subgroup of hypochondriacal patients who are closer to the anxiety disorders in general and to OCD in particular. This subgroup might respond to the newer, antiobsessional, serotonin reuptake blocking agents.

Determinants of perceived health status of medical outpatients

The aim of this study was to examine the relative contributions made by medical morbidity, psychiatric disorder, functional status, and hypochondriacal attitudes to medical patients' opinions of their overall health status. The study was conducted in the general medical clinic of a large academic teaching hospital. Consecutive clinic visitors on randomly selected days were screened with a hypochondriasis self-report questionnaire, since the overall project was designed as a study of hypochondriasis. A random sample of the patients below a pre-established cutoff (n = 100), along with all those exceeding the cutoff (n = 88), returned to undergo a research battery. For this analysis, a representative sample of the entire clinic was reconstituted by weighting the data from patients above and below the screening cutoff in proportion to their prevalence in the clinic. Measures of psychiatric disorder (the Diagnostic Interview Schedule), personality disorder, functional status and disability, medical morbidity (from physician ratings and medical record audit), and hypochondriacal attitudes were obtained. Patient self-ratings of global health status were significantly correlated with aggregate medical morbidity (r = 0.36; P less than 0.001); psychiatric morbidity (r = 0.48; P less than 0.001); functional disability (for intermediate activities of daily living, r = 0.62; P less than 0.001); hypochondriacal attitudes (r = 0.79; P less than 0.001); and with the tendency to somatize (r = 0.77; P less than 0.001). Using multiple regression analysis, the most powerful correlates of perceived global health were hypochondriasis, somatization and disability (model R2 = 0.762).(ABSTRACT TRUNCATED AT 250 WORDS)