... SYMPTOM REPORTING AND SOMATIZATION IN FAMILY MEDICINE. James Robbins and Laurence Kirmayer. Institute of Community and Family Psychiatry.
ILLNESS COGNITION, SYMPTOM REPORTING AND SOMATIZATION IN FAMILY MEDICINE
James Robbins and Laurence Kirmayer Institute of Community and Family Psychiatry McGill University
Biomedical practitioners hope for a simple correspondence between clinical presentation and organic pathology. Unfortunately, illness behaviour supervenes to make the relationship between illness and disease exceedingly complex. Style of symptom presentation interacts with the structure of the health-care system to determine whether patients' distress is accurately recognized and alleviated. From 20 to 84 percent of patient visits to primary care are for somatic complaints that receive no organic diagnosis (Kellner, 1985). When psychosocial factors are noted as part of their presentations, patients with obscure somatic symptoms may be described as somatizing or hypochondriacal and referred for psychiatric evaluation of "abnormal illness behaviour" (Pilowsky, 1969). When psychosocial factors are not recognized, these patients may be exposed to lengthy diagnostic and therapeutic intervention and, when no organic explanation is forthcoming, casually reassured or abruptly told their problems are imaginary. Far from being dictated by pathobiology, human suffering takes shape through thought and action. The translation of inchoate distress into symptom reports and pres~nting complaints is mediated by cognitive processes. As an outcome of the cognitive mediation of distress, people may amplify or minimize symptoms while emphasizing somatic or emotional aspects of suffering. Variations in these processes may help account for the observed clinical and sociodemographic differences in symptom reporting. The research outlined in this chapter focuses on the cognitive components of illness behaviour. Measures of several distinct cognitive styles that may be involved in the translation of distress into somatic or psychosocial symptoms are proposed. The ability to measure multiple cognitive styles that make independent contributions to the outcomes of illness experience has application to the study of everyday symptom reporting as well as to primary care patient populations who appear to somatize or psychologize their distress. Illness Cognition and Symptom Presentation While specific pathophysiological disturbances account for many of the complaints presented to physicians and much of the variation in reports of distress gathered by self-report symptom inventories, the presentation and declaration of symptoms may also be influenced by the patient's illness cognition (Leventhal, Nerenz and Strauss, 1982; Pennebaker, 1982). As the 283 S. McHugh et al. (eds.), Illness Behavior © Plenum Press, New York 1986
term is used in this chapter, illness cognition refers to the outcomes of cognitive processes that accompany each illness experience and is hypothesized to include: (1) focusing on unusual bodily sensations and feeling states; (2) recognizing these sensations or states as symptoms of a physical illness or emotional problem; and (3) attributing symptoms to physical or psychosocial cause. (1) Self-focus. An illness episode typically begins when an individual becomes aware of a change in bodily sensation or feeling state. Recognition of unusual bodily sensations is a function of attention focused on those sensations. Laboratory subjects instructed to focus on their bodies have been shown to report more somatic symptoms than subjects instructed to attend to external stimuli (Pennebaker, 1982). Similarly, scales devised to measure individual differences in self-consciousness, body focus, and introspection are correlated with reports of both affective and somatic symptoms (Fenigstein, Scheier, and Buss, 1975; Miller, Murphy, and Buss, 1981; Mechanic, 1980; Hansell and Mechanic, this volume). Symptom recognition. Once unusual sensations are noticed they must then be recognized as symptoms, that is, as evidence that something is wrong before they are likely to be declared on a self-report inventory or reported to a physician. Barsky and Klerman (1983) have proposed that hypochondriacal or somatizing patients may tend to amplify normal bodily sensations and to view them as evidence of serious disease. The chronic tendency to worry about illness and to evaluate trivial or transitory sensations as signs of illness, as measured, for example by the hypochondriasis scale of Pilowsky (1967), is related to increased symptom reports on somatic symptom checklists (Fava, Pilowsky, Pierfederici, et al., 1982; Pilowsky and Spence, 1975) and on the Center for Epidemiological Studies Depression scale (Radloff, 1977). Factorial studies by Pilowsky (1967; Pilowsky, Murrel, and Gordon, 1979) suggest that this tendency to interpret sensations as abnormal and hence view them as symptoms might be activated by such factors as worry or fear about illness, sensitivity to sensations, perceived vulnerability to illness, and the conviction that one is sick. Symptom interpretation. Given the recognition that sensations or feelings indicate an illness, expression of distress is determined by the cause attributed to the discomfort. Causal attribution, not necessarily a direct reflection of pathology, becomes increasingly subject to interpretive biases as discomforting sensations increase in vagueness, ambiguity, and location in parts of the body not directly observable (Barsky and Klerman, 1983). In the laboratory, manipulation of suggested labels can result in misattribution of identical internal sensations to feelings of hunger, need for smoking, sexual aggression, or crowding (Pennebaker, 1982). A more limited repertoire of classifications may exist for sensations clearly suspected as being symptoms of an illness. An upset stomach for example, may be interpreted psychologically as a sign of anxiety, somatically as evidence of an ulcer, or environmentally as the result of dietary indiscretion. Attributing a cause to symptoms depends on the familiarity of the condition, the illness experiences and suggestions of significant others,
1. Our use of the term illness cognition should be distinguished from that of Leventhal and colleagues (Leventhal and Nerenz, 1985; Leventhal, Nerenz, and Steele, 1985). While they propose a self-regulatory illness cognition model including common sense representations of the attributes of a symptom, plans to cope with a symptom, and appraisal of the outcomes of coping efforts, our use is restricted to the perceptual and evaluative steps leading up to and including the expression of distress as a discrete symptom. 284
previous contact with the medical profession, and social and cultural restrictions on the appropriate expression of distress (Kleinman, 1980; McKinlay, 1973; Meyer, Leventhal, and Gutmann, 1985). An outcome of these influences may be a general tendency to interpret sensations and feelings as somatic in origin, psychosocial in origin, or environmental in origin. Interpretations of symptoms in turn determine the objectification of the condition as a complaint offered to a physician. Distress, open to alternative interpretations, may also be open to alternative modes of expression. Weakness, tiredness and fatigue, for example, may be expressions of distress that have a common origin with feelings of hopelessness and worthlessness, varying only in the manner in which meaning is assigned. To summarize, symptom reporting and presenting complaints should be influenced by self-focus, symptom recognition and symptom interpretation. Heightened awareness of bodily sensations, the tendency to believe that sensations represent serious illness, and a bias toward interpreting symptoms as physical in origin should be related to increased somatic symptom reporting and the declaration of somatic symptoms to the physician. In contrast, heightened awareness of thoughts and feelings, the conviction that emotional changes are abnormal and thus reflect a serious emotional problem, and the tendency to employ psychological concepts when attributing origin to symptoms should contribute to increased psychological symptom reporting and the presentation of psychosocial symptoms to the physician. A study designed to investigate these hypotheses among family medicine patients is presented below. Measuring Illness Cognition in Family Medicine Patients attending a hospital-based family medicine teaching unit of McGill University were recruited for the study. Patients able to speak and read English and for whom their current visit was not a follow-up for a previously diagnosed problem were eligible. Subjects were sampled on varying days of the week over five months. Interviews were completed with a total of 100 patients who were visiting one of 23 staff or resident family physicians. The average age of the sample was 44.2 years; 58 percent were women; and 42 percent were currently married. The patients in the sample had an average of 12.3 years of schooling; 45 percent were working at a job for pay; and they had visited a doctor an average of 4.2 times over the last 12 months. Slightly over a quarter (27 percent) were Jewish; 13 percent French Canadian; 19 percent non-Jewish English Canadian; and 17 percent were of other nonJewish European background. Patients of West Indian, Asian, Southeast Asian, and Middle Eastern origins composed the remaining 24 percent. The illness cognition dimensions of self-focus, symptom recognition, and symptom interpretation were measured by instruments developed for this study or adapted from previous work on self-awareness and abnormal illness behaviour. The background and psychometric properties of these measures are described in the following sections. Self-focus. Chronic awareness of bodily sensations and feelings was measured by the Private Self-Consciousness scale (PSC, Fenigstein et al., 1975) and the Private Body-Consciousness scale (PBC, Miller et al., 1981). These scales identify individuals who are chronically attentive to their inner thoughts and feelings (PSC) and to their bodily sensations (PBC). The PSC is composed of ten true-false items such as "I'm generally attentive to my inner feelings", and "I'm alert to changes in my mood". It has a testretest correlation of .79 and a correlation of .32 with a physical symptom checklist (Pennebaker and Skelton, 1978). Items were internally consistent (alpha = .69) among our sample of family practice patients. 285
The PBC includes five true-false questions such as "I am quick to sense the hunger contractions of my stomach", and "I'm very aware of changes in my body temperature". It has a test-retest correlation of .69 among a sample of university students but an alpha of only .32 among our patient sample. The PSC and PBC correlate with each other at .33 among our sample of patients. (See Appendix for intercorrelations of illness cognition measures.) They are used separately and in linear combination to measure intrapsychic versus somatic focus of attention. Symptom recognition. The tendency for people to conclude that bodily sensations or feelings signify serious disease was measured indirectly. Symptom recognition should be influenced by (a) one's cognitive sense of being vulnerable to illness, (b) the degree of worry or fear about becoming ill, (c) the conviction that one has an illness and, (d) the sense of being more sensitive to symptoms than others. These beliefs might be seen as establishing an expectancy set through which new sensations are more readily experienced as symptoms of a severe illness. Items designed to measure each of these components of somatic symptom recognition were extracted from the Illness Behavior Questionnaire (Pilowsky, Spence, Cobb, and Katsikitis, 1984; items 2, 6, 20, 24, 34, 37, 39). The resulting seven items of the Somatic Symptom Recognition scale (SSR) were internally consistent (alpha = .67). Items parallel in structure to those of the SSR but modified to have emotional symptom content were designed to measure the tendency to conclude the fluctuations in feelings signify a serious emotional problem. The resulting seven-item Affective Symptom Recognition scale (ASR) includes yesno questions such as "Do you think there is something seriously wrong with your emotions", and "Do you think you might suddenly lose control of your emotions". The alpha for this scale (.82) suggests adequate internal consistency. Correlation of the ASR with the somatic recognition scale (r .64) also suggests that the belief that one's emotional symptoms are abnormal often exists together with the belief that one's somatic symptoms are abnormal, and that both beliefs may be traced to a more general feeling of personal vulnerability to illness. Symptom interpretation. The tendency to interpret symptoms as either somatic, psychological, or environmental (external) in origin was measured by the Symptom Interpretation Questionnaire (SIQ) designed for this study. The SIQ consists of 13 common symptoms such as weakness, dizziness, trouble sleeping, head~che and upset stomach. Subjects were asked to imagine that they were experiencing each symptom and hypothesize the predominate cause of each. For example, "If I got dizzy all of a sudden, I would probably think that it is because: (a) there is something wrong with my heart or blood pressure (b) I am not eating enough or I got up too quickly; or (c) I must be under a lot of stress". A forced-choice response format for each symptom allows for the computation of three scales that are the sum of somatic, affective, and normalizing attributions respectively. The scales measure the tendency to employ one interpretative type (e.g., somatic) in contrast to the other two (e.g., affective or normalizing). The forced-choice design requires that responses to only two of the three scales be used in any multivariate analysis. Response to the third scale is, by design, a perfect linear combination of responses to the other two. (2) The resulting Affective Symptom Interpretation scale (ASI) is internally
2. The Symptom Interpretation Questionnaire and other scales devised for this study are available from the authors. 286
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-..J
co
Exclusion Criteria None
Psychosocial complaints
Psychosocial complaints, vegetative symptoms of depression,
Psychosocial complaints, vegetative symptoms of depression, somatic symptoms of obscure origin Complaints or symptoms of any kind
Inclusion Criteria Psychosocial complaints with or without additional somatic complaints Complaints of vegetative symptoms of depression as specified by DSM III (APA, 1980) Pain not diagnosed as organic in origin or other somatic complaints not diagnosed as organic
Somatic complaints, all with organic diagnosis
Request for" check-up, routine test, pregnancy Diagnosed schizophrenic excluded from categorization
Psychosocial
Vegetative symptoms of depression (somaticvegetative)
Somatic symptoms of obscure (somaticobscure)
Somatic symptoms of organic origin (somatic-origin)
Health maintenance
Ineligible
Chest pain explained by angina, fatigue due to anemia, appetite loss secondary to gastrectomy
Shortness of breath, dizziness, weakness in arms and legs, hot flushes, pains in spine, pains in knees, back and shoulder pain, headaches, stomach pains
Sleeping problems, fatigue, weight gain
Depression, mood shifts, feeling stressed because of work tensions, confusion, anxiety attacks
Examples
CLASSIFICATION OF CLINICAL PRESENTATIONS IN FAMILY l1EDICINE
Clinical Presentation
TABLE 1.
consistent (alpha = .82) and reliable over a two-month period among university students (test-retest correlption = .63). (3) The comparison Somatic Symptom Interpretation Scale (SSI) has an alpha of .63 among the patient sample and a test-retest correlation among students of .52. The two scales are negatively correlated at r = -.34 for patients. Symptom self-report inventories. Affective and somatic symptom reporting was measured by the Center for Epidemiological Studies Depression scale (CES-D; Radloff, 1977) and the somatization subscale of the Symptom Checklist 90 (SCL-90; Derogatis, Lipman, and Covi, 1973). The CES-D consists of 20 items characteristic of clinical depression and, in modified form, was used to measure affective symptom reporting. The CES-D has been shown to be a reliable screening instrument for major depression in community surveys (Radloff, 1977). Items are predominantly affective although somatic and other non-affective symptoms of depression are included. In order to maintain the conceptual distinction between affective and somatic symptom reporting, the CES-D was shortened to include only the 14 purely affective or cognitive depressive symptoms. Deleted were two somatic items (my appetite was poor; my sleep was restless), two ennervation items (everything I did was an effort; I could not get going), and two nonspecific items (I was bothered by things that usually don't bother me; I talked less than usual). The somatization subscale of the SCL-90 consists of 12 somatic symptoms. (4) The scale was developed as a measure of subjective distress arising from the perception of bodily dysfunction. It has demonstrated high internal consistency (alpha .86) and correlates highly with MMPI-based scales of bodily symptoms (r = .66) and organic symptoms (r = .62) (Derogatis, Rickels, and Rock, 1976). Clinical presentation. The classification of patient's clinical presentations has proven to be extraordinarily difficult (McWhinney, 1972; Stewart, McWhinney, and Buck, 1975; Weyrauch, 1984). It is likely that no entirely satisfactory scheme can be devised simply because patients do not present with a single problem and the priority of their problems shifts with information from others. Presentations also must be understood as the result of doctor-patient interaction where the physician assists with language for distress and patients, gauging the receptiveness of their doctors, wait for an appropriate opening to declare their problems. Realizing the limitations of classifying overlapping, heterogeneous and evolving complaints, the categorizations listed below approximate groups of clinical and theoretical significance. To maintain the distinction between affective and somatic presentations, as well as between somatic complaints of obscure origin and organic somatic complaints, and to arrive at mutually exclusive classifications, presentations have been based on exclusion criteria. Criteria used in classifying presentations and examples of complaints grouped in each category are presented in Table 1. Reading down the table, inclusion criteria for presentations listed higher in order are exclusion criteria for presentations listed lower in order. For example, a patient presenting with psychosocial difficulties and vegatative symptoms of depression is classified as a psychosocial presentation. Similarly, a patient presenting with somatic complaints that receive clear organic diagnoses and at least one somatic complaint of obscure origin is classified as presenting with somatic symptoms
3.
Robbins and Kirmayer, unpublished data, N
= 140.
4. The response format of the somatization subscale was modified slightly to be consistent with the CES-D scale. 288
N OJ CD
a
-.27* -.18* .10 .22'" .07 -.62'"
-.03 .09 -.09 .04 -.15
- .13
-.04
.18'" - . 28'" .14
Selfconsciousness
.20'"
- .11
Body consciousness
Self-focus
-.47'"
. 22'"
-.10 -.06 .15 -.04
- .13
.07 -.05
Somatic recognition
-.54'"
.06
- .13
-.16 .07 .18
. 26'" -.12 -.14
Affective recognition
Symptom Recognition
.46
.17'~
.12 .21* .08 -.16
- .11
-.09 .21*
Somatic interpretation
-.17
-.08
.05 -.21* .00 .16
.21* -.08 -.08
Affective interpretation
Symptom Interpretation
CORRELATIONS OF ILLNESS COGNITION MEASURES WITH SOCIOCULTURAL VARIABLES, LIFE EVENTS, PHYSICIAN VISITS, AND SOCIAL DESIRABILITY
Correlations based on 100 subjects except for RD16, computed on a subsample of 25 *p
