The Dying Role: Its Relevance to Improved Patient Care.

SOCIETY is failing to meet the obligation it has to its dying members. Persons with terminal illnesses suffer isolation and neglect in hospitals, receive overzealous treatment by physicians, and are kept in ignorance of their situation by families and medical personnel. Evidence for these statements has come from observers of the medical care system and from dying patients themselves (Kübler-Ross, 1969; Reynolds and Kalish, 1974; Sudnow, 1967). In the nineteenth century it was common for persons to die in the familiar environs of their homes, surrounded by grieving families from whom they parted in a meaningful manner (Blauner, 1966). Dying persons of today no longer fill a well-defined social role. Instead, the distinction between the roles of sick and dying persons has been lost and, in the resulting confusion, the care of dying people has suffered. The purpose of this article is to clarify the distinction between the dying and sick roles, identify the signs of existing role confusion, suggest ways in which this confusion may be corrected, and show how reestablishment of the dying role can result in improved care of dying people. The important part physicians play in defining sick and dying roles will be emphasized.

A blind re-analysis of the Iowa family study of obsessive-compulsive disorder.

We present results from a re-analysis of the Iowa family study of obsessive-compulsive disorder (OCD) that previously concluded the disorder was not familial. These conclusions were based on Diagnostic Interview Schedule results of first-degree relatives (FDRs) and not a best estimate diagnosis (BED). For the re-analysis we reviewed raw data on OCD and control probands and their FDRs. Relatives had been assessed through structured interviews, validated questionnaires, family history, and medical records in some cases. BEDs were assigned through a blind consensus procedure employing DSM-IV criteria. The data were analyzed using logistic regression with generalized estimating equations to account for within family correlations. BEDs were assigned to 32 OCD probands, 31 control probands, and 352 FDRs, including 249 FDRs who were interviewed directly and 103 FDRs who were unavailable or deceased. Lifetime prevalence of definite/probable OCD was significantly higher in the FDRs of OCD probands than controls (10.7% vs. 3.8%, OR=3.04, p=0.026). FDRs of OCD probands had significantly higher rates of depressive illness than relatives of controls. Depression of any type in relatives was predicted by the proband's depression history. We conclude that OCD is familial. The re-analysis highlights the importance of the BED procedure in family studies.

Somatic symptoms and psychological characteristics associated with insomnia in postmenopausal women.

OBJECTIVE: The aim of the study was to assess the association of sleep disturbance with psychological characteristics, somatic symptoms and previously identified risk factors. METHODS: Data were from 148,938 postmenopausal women enrolled in The Women's Health Initiative who provided cross-sectional information about psychological characteristics, somatic symptoms and the character of their sleep. Overall sleep quality was based on the Women's Health Initiative Insomnia Rating Scale (WHI IRS), a measure that assessed five types of sleep disturbance. RESULTS: Three factors accounted for nearly 20% of the variation in the WHI IRS: a scale for somatic symptoms, daytime restlessness and either depression or emotional well-being. Other independently associated factors were night sweats, pain and worry about expressing anger. Several factors that had been linked to sleep disturbance in other studies were found to have at most a weak independent association in this analysis. These included income, education, marital status, activity level, obesity level, hot flashes, coffee drinking and smoking. CONCLUSION: Factors strongly associated with sleep disturbance in this study deserve further evaluation to determine the reasons for the association and whether the associations suggest possible treatments for sleep disturbance.

Effects of continuity of care and patient dispositional factors on the physician-patient relationship.

BACKGROUND: We developed a questionnaire to examine the influence of physician and patient variables on the quality of the physician-patient relationship. METHODS: More than 300 family medicine patients completed self-report measures of the physician-patient relationship and variables likely to influence it. RESULTS: The quality of relationship was related to continuity of physician care (having a primary physician, duration of that relationship, and frequency of visits) and to patient dispositional variables (neuroticism, positive and negative affectivity) but not to demographic variables. The regression model included having a primary physician, duration of relationship with that physician, and positive affectivity. Relationship quality was, in turn, associated with outcomes (adherence to care, treatment response, satisfaction with care, and commitment to physician). CONCLUSIONS: The quality of physician-patient relationship is influenced by physician continuity and patient dispositional variables. Better understanding of these may contribute to the therapeutic potential of this important relationship.

A taxometric study of hypochondriasis symptoms.

Hypochondriasis has been conceptualized as both a distinct category that is characterized by a disabling illness preoccupation and as a continuum of health concerns. Empirical support for one of these theoretical models will clarify inconsistent assessment approaches and study designs that have impeded theory and research. To facilitate progress, taxometric analyses were conducted to determine whether hypochondriasis is best understood as a discrete category, consistent with the DSM, or as a dimensional entity, consistent with prevailing opinion and most self-report measures. Data from a large undergraduate sample that completed 3 hypochondriasis symptom measures were factor analyzed. The 4 factor analytically derived symptom indicators were then used in these taxometric analyses. Consistent with our hypotheses and existing theory, results supported a dimensional structure for hypochondriasis. Implications for the conceptualization of hypochondriasis and directions for future study are discussed.

Hypochondriacal symptoms associated with a less therapeutic physician-patient relationship.

The purpose of this study was to examine the association between hypochondriacal symptoms and the physician-patient relationship. Family medicine patients (n = 310) completed self-report measures of hypochondriacal symptoms, quality of physician-patient relationship, and variables likely to influence that relationship. These variables included physician relationship factors, such as duration of relationship and frequency of visits, as well as patient characteristics, such as neuroticism and positive and negative affectivity. Hypochondriacal symptoms were negatively correlated (r = -.24) with the quality of physician-patient relationship. In addition to hypochondriacal symptoms, the regression model included having a primary physician, length of relationship with that physician, frequency of physician visits, and the level of positive affectivity in the patient. Hypochondriacal symptoms appear to be associated with a less therapeutic physician-patient relationship. Physicians must recognize symptoms of this kind in order to properly address the relationship needs of their patients.

Community physicians' strategies for patients with medically unexplained symptoms.

BACKGROUND AND OBJECTIVES: This qualitative study examined the management strategies that community primary care physicians use for patients with medically unexplained symptoms (MUS). METHODS: Volunteer community physicians identified patients with chronic MUS. The physicians and patients were interviewed separately about management strategies used and their effectiveness. Thematic analyses were used to categorize these strategies. RESULTS: Thirty-six physicians and 49 of their patients completed interviews. Physician strategies considered effective by physicians and patients included medical treatment, exploring causes of symptoms with tests and referrals, attentive listening, validating complaints, demonstrating commitment over time (eg, assuring patients of continued care, allowing extended office visits, and returning phone calls), providing clear explanations of symptoms and management, and providing explanatory models for the linkage between psychosocial factors and physical symptoms. Strategies used that conflict with published recommendations included ordering potentially unnecessary diagnostic tests, scheduling patients on demand, and prescribing narcotics. Physicians expressed concerns about these strategies but considered the benefits for specific patients worth the costs and risks. CONCLUSIONS: Physicians used some strategies recommended in the medical literature and others not recommended. The ability to effectively implement certain strategies may depend on having a long-term relationship with a patient and a health care environment that permits extensive patient-physician interaction.

A reconceptualization of the somatoform disorders.

Since its introduction in DSM-III, the Somatoform Disorders category has been a subject of controversy. Critics of the grouping have claimed that it promotes dualism, assumes psychogenesis, and that it contains heterogeneous disorders that lack validity. The history of these disorders is one of shifting conceptualizations and disputes. A number of changes in the classification have been proposed, but few address problems that arise with the current formulation. The authors propose a dimensional reconceptualization based on marked and persistent somatic distress and care-eliciting behavior. This formulation is based on the interpersonal model of somatization. The authors propose testing of this conceptualization and indicate how this might be done.

Distinguishing between hypochondriasis and somatization disorder: a review of the existing literature.

A valid classification is important for further understanding of the somatoform disorders. The main disorders in this grouping - somatization disorder and hypochondriasis - have lengthy historical traditions and are defined in a contrasting manner. Various authors point to distinguishing demographic and clinical features, but there have been few direct comparisons of patients with these disorders. A review of the literature indicates those domains where differences are most likely to be found. Research assessing these may serve to refine and validate these key somatoform categories and/or dimensions.

Empirically identified goals for the management of unexplained symptoms.

BACKGROUND AND OBJECTIVES: Effective management of patients with medically unexplained symptoms may be influenced by physicians' goals. This study's objective was to identify physicians' goals for managing primary care patients with unexplained symptoms. METHODS: This was a qualitative study of patients and clinicians from primary care clinics in Iowa and Illinois. Interviews were conducted with 47 patients who had unexplained symptoms and the 36 primary care clinicians who managed them. The interviews were transcribed and coded independently by two investigators. Categories for coding responses were derived from the data and the literature. RESULTS: Eleven goals were identified and grouped into four classes based on whether they were disease centered, patient centered, society centered, or clinician centered. The three goals most commonly held by patients were patient centered: clinician support (62%), functional improvement (45%), and patient coping (43%). The most common clinician goals were symptom alleviation (38%), patient coping (32%), and functional improvement (30%). Only one clinician (2%) cited making the patient feel supported as a goal. CONCLUSIONS: The goals of clinician support and patient coping appear to have value to patients beyond being means for achieving symptom alleviation. Although receiving physician support is an important goal for patients, it was not a commonly recognized goal by physicians. Clearly identified management goals may improve the care of patients with medically unexplained symptoms and help clinicians achieve greater satisfaction with the management of these patients.

Interpersonal psychotherapy for somatizing patients.

The interpersonal model is important for understanding somatizing behavior. According to this model, somatizing behavior is a form of interpersonal communication driven by insecure attachment. Interpersonal psychotherapy (IPT) is a time-limited, manual-based treatment designed to relieve symptoms and improve interpersonal functioning. Based on our experience using IPT with somatizing patients, we recommend a series of strategies for its successful implementation. These strategies include an emphasis on the therapeutic alliance within a bilaterally negotiated treatment contract, and aiming for improvement in interpersonal functioning rather than for alleviation of physical symptoms. Specific techniques include the use of bridging metaphors, communication analysis, and genuine positive reinforcement. With a focus on communication in a time-limited frame, fostered by a strong collaborative relationship, IPT appears to be a promising method of reducing somatizing behavior. We urge further research on the efficacy of this form of therapy.

Panic and phobic anxiety: associations among neuroticism, physiological hyperarousal, anxiety sensitivity, and three phobias.

A dimensional and psychometrically informed taxonomy of anxiety is emerging, but the specific and nonspecific dimensions of panic and phobic anxiety require greater clarification. In this study, confirmatory factor analyses of data from a sample of 438 college students were used to validate a model of panic and phobic anxiety with six content factors; multiple scales from self-report measures were indicators of each model component. The model included a nonspecific component of (1) neuroticism and two specific components of panic attack, (2) physiological hyperarousal, and (3) anxiety sensitivity. The model also included three phobia components of (4) classically defined agoraphobia, (5) social phobia, and (6) blood-injection phobia. In these data, agoraphobia correlated more strongly with both the social phobia and blood phobia components than with either the physiological hyperarousal or the anxiety sensitivity components. These findings suggest that the association between panic attacks and agoraphobia warrants greater attention.

The limited effect of screening for depressive symptoms with the PHQ-9 in rural family practices.

CONTEXT: Previous studies have found that routine screening for depression does not improve patient outcome unless it is combined with case management. However, these studies were conducted before the widespread use of SSRIs or in settings other than traditional primary care. PURPOSE: This study investigated whether screening for depressive symptoms improves outcomes for depressed patients seen in rural fee-for-service primary care offices. METHODS: Depression screening was conducted at 2 private rural clinics in Iowa using the PHQ-9. Patients with depressive symptoms were randomized to the control group or the intervention group, where providers were given completed PHQ-9 questionnaires at the baseline visit. The outcome PHQ-9 scores were assessed by telephone at 4, 10, and 24 weeks after the index visit. FINDINGS: A total of 861 patients were screened for depressive symptoms; 51 subjects enrolled in the trial. The intervention and control groups did not significantly differ with respect to changes in PHQ-9 scores at any of the 3 follow-up times. They also did not differ with respect to the proportion of subjects who were actively managed with medication or by referral to a mental health specialist: 46% vs 33% (P = .38) for all subjects and 50% vs 50% (P = .96) for subjects with major depression at baseline. CONCLUSIONS: Screening for depressive symptoms with the PHQ-9 in 2 rural medical clinics did not significantly increase physicians' active management of depression or lead to improved patient outcomes.

Prevalence and correlates of illness worry in the general population.

The prevalence and correlates of illness worry in the general population were investigated in a representative sample. The authors screened residents of the United States by telephone, and more detailed interviews were conducted with 123 respondents who reported at least 1 month of worry about serious illness in the past 12 months and an equal number of randomly selected persons without such worry. Data on demographic characteristics, medical and psychiatric conditions, functional impairment, and health care utilization were collected. At least 1 month of worry was endorsed by 13.1% of the screened population. Correlates of worry included a cluster of psychiatric conditions (major depressive episode, panic attacks, and generalized anxiety disorder) and three clusters of physical conditions (heart disease, cancer, and other diseases). Worry about serious illness was associated with functional impairment and health care utilization.

NAG level differences in panic disorder and agoraphobia.

It is not clear if panic disorder (PD) and agoraphobia are variants of the same disorder or distinct diseases. A laboratory test could help resolve this issue. Research has shown that levels of the urinary lysosomal enzyme N-acetyl-beta-glusosaminidase (NAG) differ between patients with various psychiatric disorders. This study examined whether NAG levels would be similar in PD and agoraphobia, suggesting the two disorders may be the same disorder, or different, suggesting they may be distinct diseases. Differences found could suggest either qualitative or quantitative distinctions between these disorders. Ninety-one agoraphobics were compared to 24 patients with panic disorder. NAG levels were significantly lower in panic patients compared to agoraphobic patients 9.7+/- 8 versus 22+/- 21; P< .005. These data provide limited support for the hypothesis that PD and agoraphobia may be distinct diseases.

Assessment of the hypochondriasis domain: the multidimensional inventory of hypochondriacal traits (MIHT).

Although hypochondriasis is associated with the costly use of unnecessary medical resources, this mental health problem remains largely neglected. A lack of clear conceptual models and valid measures has impeded accurate assessment and hindered progress. The Multidimensional Inventory of Hypochondriacal Traits (MIHT) addresses these deficiencies with scales that correspond to a 4-factor model. The MIHT was built with construct validity as a guiding principle and began with an item pool that broadly assessed dimensions identified in the literature. The items were administered to large samples; factor analyses of the responses led to item pool revisions and scale refinements. Multiple studies validated the final MIHT scales and 4-factor model; these findings suggest that the MIHT will contribute to theory and research.

Relationship between hypochondriacal concerns and personality dimensions and traits in a military population.

Our aim was to examine the relationship between personality dimensions and hypochondriacal concerns and somatic symptoms in a military population. The Schedule of Nonadaptive and Adaptive Personality along with measures of hypochondriacal concerns and somatic symptoms were administered to 602 military veterans who had been on active duty during the 1991 Gulf War. Factor analyses identified six separable dimensions-two of hypochondriacal concerns, two of somatic symptoms, and two of possible mechanisms of symptom generation-for study. Multiple regression models determined the proportion of variation in these measures of somatic distress explained by personality scales. Personality measures explained between 26% and 38% of the variance in hypochondriacal concerns and somatic symptoms, and Negative Temperament accounted for most of this. Moderately strong positive correlations were observed between trait scales Mistrust, Low Self-Esteem, and Eccentric Perceptions and the various measures of somatic distress. Thus, when Negative Temperament was taken into account, few significant correlations between personality measures and hypochondriacal concerns or somatic symptoms remained. Negative temperament or neuroticism is strongly associated with hypochondriacal concerns. Important features of hypochondriasis and somatic distress appear to lie within the domain of personality. It remains for future research to show whether negative temperament is a vulnerability factor for hypochondriasis or hypochondriasis is itself a personality disorder.

Risk factors for hypochondriacal concerns in a sample of military veterans.

OBJECTIVE: The aim was to examine the influence of combat exposure and other risk factors on the development of hypochondriacal concerns among veterans of the Gulf War and to learn whether these concerns might be a source of increased symptom reporting among them. METHOD: Six hundred two veterans who were deployed to the Gulf or elsewhere during the 1991 war took part in a two-phase study of symptoms and illnesses occurring among these veterans. Hypochondriacal beliefs and attitudes were assessed by the Whiteley Index and somatic symptoms by a factor-analytically derived measure. Multiple regression models were developed for these outcomes. RESULTS: Hypochondriacal concerns were significantly associated with level of education, personal history of depression, number of prewar physical conditions, family history of functional syndromes, negative and positive temperament and disinhibition, military combat, level of military preparedness, social support, and perceived life stress. Somatic symptoms were associated with these same variables, as well as branch of service, family history of physical conditions, combat, and level of combat exposure. A regression model for hypochondriacal concerns included the number of prewar physical conditions, negative temperament, lack of social support, and perceived life stress. CONCLUSIONS: Hypochondriacal concerns were not strongly related to combat exposure. Consequently, it is not likely that such concerns account for increased symptom reporting among the veterans studied. Hypochondriacal concerns appeared to arise in response to threats posed by physical illness. Vulnerability to such threats appeared to center on the personality dimension of negative temperament. This model may serve as a guide to future investigations.

Occurrence of cancer among people with mental health claims in an insured population.

OBJECTIVE: The objective of this research is to determine whether people with mental disorders are at increased risk for the subsequent development of malignancies compared with people without mental disorders. METHODS: This is a retrospective cohort study of administrative claims data. The study population included 722,139 adults who filed at least one medical claim from 1989 to 1993. The mental disorder cohort included people with a) one psychiatric hospitalization, b) one outpatient psychiatrist visit, or c) two outpatient mental health claims occurring at least 6 months before a cancer claim. The controls were subjects filing claims for medical services who had no mental health visits. We calculated age-stratified odds ratios (ORs) for development of malignancy. RESULTS: People with mental disorders were no more or less likely to develop a malignancy than those without after adjusting for age (women: OR, 1.03; 95% confidence interval [CI], 0.95-1.12; men: OR, 1.10; 95% CI, 0.97-1.24). People with mental disorders, however, developed cancer at younger ages and had increased odds of primary central nervous system tumors (women: OR, 2.12; 95% CI, 1.40-3.21; men: OR, 2.09; 95% CI, 1.22-3.59) and respiratory system cancers (women: OR, 1.57; 95% CI, 1.13-2.19; men: OR, 1.52; 95% CI, 1.09-2.12). CONCLUSIONS: Insured people with mental disorder claims had an increased risk of certain malignancies and developed malignancies at younger ages. The increased odds of respiratory tumors are likely secondary to increased rates of smoking among people with mental disorders and support use of smoking cessation interventions in this population. The increased odds for brain tumors may reflect only the early presence of mental symptoms, or a true association between the two conditions. Further study of these findings is mandated.

Hypochondriacal concerns in panic disorder and major depressive disorder: a comparison.

OBJECTIVE: To gain perspective on the relationship between hypochondriasis and panic disorder, we compared the occurrence of hypochondriasis in patients with panic disorder (N= 59) and major depressive disorder (N= 27). METHODS: Patients who participated in separate drug treatment trials were assessed at baseline and eight weeks using the Whiteley Index of Hypochondriasis. RESULTS: At baseline, the Whiteley Index score was greater for patients with panic disorder than for those with major depressive disorder. At eight weeks, a statistically significant reduction in the mean hypochondriasis score was observed in panic patients who had improved but not in major depressive patients who had improved. Modest correlations were observed between hypochondriasis and symptoms of panic and major depressive disorder, but in depressed patients, hypochondriasis was positively correlated with anxiety symptoms as well. CONCLUSION: A unique relationship appears to exist between hypochondriasis and panic disorder. The nature of this relationship and its implications for classification are discussed.