- Email: [email protected]
Psychosomatic disorders in the community
Journal of Psychosomatic Research, Vol.
16, pp. 381 to 386. Pergamon Press. 1972. Printed in Great Bri[tain
PSYCHOSOMATIC DISORDERS IN THE COMMUNITY* M. R. EASTWOOD'~ a n d M. H. TREVELYAN~ (Received 25 May 1972)
THE W o r l d H e a l t h O r g a n i s a t i o n C o m m i t t e e on P s y c h o s o m a t i c D i s o r d e r s [1] has p o i n t e d o u t the " P s y c h o s o m a t i c P a r a d o x " wherein the t e r m has two meanings. Firstly, there is the holistic usage, e n d o r s e d by the C o m m i t t e e , which stresses t h a t m a n in health and disease functions as a p s y c h o s o m a t i c unit. Secondly, the t e r m is e m p l o y e d to describe disorders which occur specifically following stress u p o n a p a r t i c u l a r o r g a n system, e.g. in hypertension, peptic ulcer, ulcerative colitis a n d r h e u m a t o i d arthritis. The latter c o n c e p t was r e g a r d e d by the C o m m i t t e e as being controversial and, when " l i m i t e d to certain disorders the u n i t a r y a p p r o a c h to medicine is undermined, the m i n d - b o d y d i c h o t o m y is reaffirmed a n d a t e m p t a t i o n is offered to neglect p s y c h o l o g i c a l factors in some d i s o r d e r s a n d somatic factors in others". However, it was a g r e e d t h a t the s t a n d p o i n t s were c o m p l e m e n t a r y a n d the C o m m i t t e e suggested t h a t the e x p e r i m e n t a l evidence showed t h a t psychological stress was a p o t e n t p a t h o genic influence. Referring to e p i d e m i o l o g i c a l work, the C o m m i t t e e t h o u g h t the m a i n p r o b l e m s related to o b t a i n i n g p o p u l a t i o n samples a n d clear definitions o f p s y c h o s o m a t i c disorder. It was c o n s i d e r e d t h a t since p s y c h o n e u r o t i c s y m p t o m s a n d p s y c h o s o m a t i c d i s o r d e r s often occur in the same individual this indicates a general type o f p s y c h o p h y s i o l o g i c a l instability r a t h e r t h a n separate disorders o f either somatic or p s y c h o n e u r o t i c origin. C o o p e r [2] r e c o m m e n d e d t h a t psychological d i s t u r b a n c e a n d physical illness s h o u l d be r e g a r d e d as i n d e p e n d e n t variables a n d a search m a d e for statistical relationships between them. By this m e a n s a m o r e scientific f o r m u l a t i o n o f p s y c h o s o m a t i c disease m i g h t be reached. An epidemiological investigation of 11 psychosomatic disorders in terms of lifetime prevalence among an urban population aged 20-59 yr was carried out by Rennie and Stole [3]. They found the psychological dimension of tension-anxiety correlated with the majority of the somatic disorders. Sainsbury [4] investigated the relationship between psychosomatic disorders and neurosis in general out-patient clinics. A psychosomatic disorder was so described if the diagnosis had appeared in the works of at least two of six writers of recent works on psychosomatic medicine. Each patient, chosen at random, completed the Maudsley Personality Inventory. The condition from which the patient suffered was placed into one of four operationally defined groups: psychosomatic, possibly psychosomatic, control or neurotic. Patients in the psychosomatic and possibly psychosomatic groups were found to have significantly higher scores on neuroticism than the controls and the psychosomatic patients were considerably more introverted than the controls. It was considered that the results indicated that psychosomatic diseases were distinct entities and that there was some evidence to suggest that they were associated with either a dysthymic or an hysterical personality. Kreitman et aL [5] examined the relationship between psychiatric, psychosomatic and organic illness in a general practice population. The investigators found no positive correlations between those categories of illness and concluded that previous reports of a positive concordance were indicative not so much of a true association as the fact that the problem of self-referral among the patients had not been overcome. Rawnsley [6] has also emphasized the problems of case-selection in psychosomatic research. * From the Institute of Psychiatry, De Crespigny Park, Denmark Hill, London. t Present Address: Epidemiology Section, Clarke Institute of Psychiatry, 250 College St, Toronto, Ontario, Canada. :~Department of Clinical Epidemiology and Social Medicine, St. Thomas's Hospital, London. 381
382
M . R . EASTWOODand M. H. TREVELYAN
He thought that convincing evidence of a positive association between somatic pathology and psychological factors could only be answered when the detection of somatic pathology remained independent of the subjects' decision to seek advice and measures of somatic pathology were insulated from the effects of attitudes and response set. Shepherd et al. [7] in a psychiatric survey of general practices in London demonstrated a rate of 45'7 per 1000 at risk for psychophysiologic disorders and this compared reasonably well with the figure from a similar survey in Baltimore. They found that the 'psychiatric-associated' conditions ranged from psychosomatic disorders to physical conditions elaborated by psychological reactions. There were wide variations between practitioners regarding diagnostic reliability and it was evident that there was a spectrum of illness from classic psychoneuroses to the emotional concomitants of chronic physical disease. They argued the need for a nomenclature which would specify the psychological components in physical disease. T h e s t u d y t o b e d e s c r i b e d in this p a p e r was c o n c e r n e d w i t h testing the h y p o t h e t i c a l r e l a t i o n s h i p b e t w e e n p h y s i c a l a n d p s y c h i a t r i c disorder. It h a d the m e t h o d o l o g i c a l a d v a n t a g e o f t a k i n g a c r o s s - s e c t i o n a l v i e w o f t h e p a t i e n t s ' clinical state a n d u s e d o b j e c t i v e d a t a i n d e p e n d e n t l y c o l l e c t e d f r o m a r a n d o m l y selected g e n e r a l p r a c t i c e p o p u l a t i o n . T h e p h y s i c a l a n d p s y c h i a t r i c assessments w e r e m a d e q u i t e s e p a r a t e l y f r o m o n e a n o t h e r , b y different observers, at a h e a l t h s c r e e n i n g survey. A l t h o u g h t h e p a t i e n t s ' c o m p l a i n t s h a d to be t a k e n i n t o a c c o u n t f o r s o m e o f the d i a g n o s t i c assessm e n t s , t h e use o f strict c r i t e r i a f o r d i a g n o s i s r e d u c e d t h e p o t e n t i a l bias t o the m i n i m u m . It has b e e n s h o w n e l s e w h e r e t h a t t h e r e was a significant excess o f p h y s i c a l disease in t h e p s y c h i a t r i c as c o m p a r e d w i t h the c o n t r o l g r o u p ( E a s t w o o d a n d T r e v e l y a n , [8]) a n d t h a t this o c c u r r e d in p a r t i c u l a r w i t h c o r o n a r y h e a r t disease ( E a s t w o o d a n d T r e v e l y a n , [9]). I n this p a p e r w e are c o n c e r n e d w i t h the d i s t r i b u t i o n o f s o - c a l l e d p s y c h o s o m a t i c disorders. MATERIAL A N D METHODS The opportunity to carry out the study arose when the Department of Clinical Epidemiology and Social Medicine at St. Thomas's Hospital, London, carried out a screening survey in a South-East London borough. The purpose of this survey was to evaluate screening procedures. One of us (M.R.E.) participated in the psychiatric aspect of the screening, whereas the other (H.T.) was concerned with organisation and management of the screening procedure. A randomly determined half of all individuals aged 40-64 who were registered with a group practice in the borough were invited to attend the screening survey. The sampling was carried out by family. The names of couples and single people within the age-range were arranged alphabetically and every alternate pair or individual was selected. Couples with one partner outside the age range were accepted for the screening survey but only the spouse within the inclusive age-range was eligible for the study described because of the problem of obtaining matched controls. Of the 2223 sent an invitation (and if necessary a reminder) 1471, or 70 per cent, accepted and were screened. There were equal numbers of each sex, 90 per cent were married and 58 per cent were from the RegistrarGeneral's Social Class III (clerical and skilled manual occupations). The non-responders comprised 20 per cent who refused the invitation for screening and 10 per cent from whom no answer was received. Scrutiny of medical histories held on the Executive Council cards of the non-responders failed to demonstrate that their records indicated an excess proportion of neurotics as compared with the responders, although there was a trend for them to be older in two of the general practitioners' lists and to consult less frequently in three out of the five group practitioners' lists. The screening procedure consisted of three parts: 1. The completion of a questionnaire by each patient, with items related to both physical and psychiatric disorder. 2. Physical screening tests which covered the range of body systems and wherever necessary a clinical psychiatric interview. 3. A physical examination carried out by the patient's general practitioner two weeks later after all the initial screening results had been collated. The general practitioner also abstracted the past medical history from the patient's medical records and stated whether the conditions demonstrated at the survey were known to him. The psychiatric sample was identified using an initial screening instrument consisting of 20 items from the Cornell Medical Index known to discriminate between those with and those without a
Psychosomatic disorders in the community
383
psychiatric disorder in general practice (Eastwood [10]). Those who gave five or more positive responses were regarded as potential psychiatric cases and those with no positive responses as potential control cases. Clinical psychiatric interviews were then given to high scorers on the psychiatric items on the questionnaire (by M.R.E.), using a standardized interview schedule of known reliability (Goldberg et aL [11]). In order to obtain controls, a proportion of those with no positive responses on these items, and who demographically matched the high scorers, was also interviewed. The psychiatric sample was therefore matched for age, sex, marital status and Registrar-General's Classification of Social Class with a control group free from psychiatric disorder. The details of the psychiatric screening have been given elsewhere [12]. The final number of matched pairs, 37 male and 87 female, was 124. In order to compare the distribution of physical disease between the two groups it was necessary to classify the wide range of physical disease identified during the screening survey. A number of possible ways of doing this were considered: by organ system, duration, severity and whether acute or chronic. As, except for cardiovascular and respiratory disease, classification by organ system had limited application and as duration could not be measured accurately, it was decided to classify by severity. It seemed to us that most of the conditions identified would be chronic since acute illness would usually have precluded attendance at the screening survey. A n operational classification into 'Major' and 'Minor' disease was therefore devised. Any condition regarded as being liable to 'threaten or shorten life' was placed in the Major category and all others were placed in the Minor category. Similar classifications have been used elsewhere [5, 13]. Agreement was reached between four research psychiatrists, with considerable medical experience, on the categories to which each physical condition would be assigned. The diagnoses employed for the puposes of comparison were based upon those stated in the College of General Practitioners' short list of the International Classification of Disease [14]. Any physical condition which was included in the list compiled by Sainsbury [4] was called 'Psychosomatic'.
RESULTS The distribution of the conditions which occurred, from Sainsbury's list, was then compared for the psychiatric and control samples. This is shown in Table 1.
TABLE 1 . - - T H E
DISTRIBUTION OF PSYCHOSOMATIC DISEASE AMONG THE PSYCHIATRIC AND CONTROL GROUPS BY SEX
The psychosomatic disorders Major
Males Psychiatric Control
Females Psychiatric Control
Coronary heart disease Hypertension Asthma Diabetes Thyrotoxicosis Rheumatoid arthritis
11 3 0
Total Minor Chronic nasal infection Seborrhoeic dermatitis Psoriasis Eczema Prolapsed intervertebral disc Peptic ulcer Cervical erosion Menorrhagia/irregular menstruation Fungal infection
1
2
1
2
0 0 0
0 0 0
4 13 0
6 19 1
Total
3
3
21
33
37
37
87
87
Total patients
4 1 0
20 9 1
10 5 0
1
0
0
1
0 0
0 0
2 4
0 1
15
5
36
17
1 1
0 0
0 0
0 0
0 0 0
1 0 0
1 1 1
2 2 1
384
M . R . EASTWOODand M. H. TREVELYAN
Only two-thirds of the conditions in Sainsbury's list are included in the Table as the others did not occur in the samples examined. Obesity was excluded due to problems of definition but the mean and standard deviations of Quetelet's Index [15] did not differ between the psychiatric and control groups. Except for coronary heart disease and menstrual disorders the individual conditions were sparsely distributed. The distribution of Major psychosomatic disorder by individual is shown in Table 2. TABLE 2.
THE DISTRIBUTION OF MAJOR PSYCHOSOMATIC DISORDER BY INDIVIDUAL IN THE PSYCHIATRIC AND CONTROL GROUPS
Psychosomatic disorders by individual
None One Two Total Total patients Males Z ~ = Females Z 2 = Total Z z =
Male Psychiatric Control
%
%
64"9 35' 1 -100"0 37
86'5 13"5 -1000 37
Female Psychiatric Control
%
%
632 333 3"5 100'0 87
840 125 3"5 100'0 87
Total Psychiatric Control
%
%
63"7 33"9 2'4 1000 124
84-7 129 24 1000 124
4'6982; 1 d.f. p < 0'05 9"5746; 1 d.f.p<0'005 14"2366; 1 d.f.p<0001
The excess of Major psychosomatic disorder was significant for males, females and the tolal psychiatric sample. Whereas with men the difference was largely due to coronary heart disease, in the women the conditions were more broadly based, with an excess of coronary heart disease, hypertension, rheumatoid arthritis and the only cases of asthma and thyrotoxicosis. Minor psychosomatic disorders, of which there were only six conditions altogether among the males, were equally divided between the male psychiatric and control groups. There was a trend for the female control patients to have more Minor psychosomatic disorders than the psychiatric cases but not to a significant degree. This difference was largely due to an excess of gynaecological and menstrual disorders among the controls and could be partly explained by the fact that more in the psychiatric group had undergone the menopause, especially by hysterectomy, and this group, therefore, was less liable to menstrual disorders. The tendency for disease to cluster in some individuals, as described by Hinkle and Wolff [16, 17], which occurred when all diseases were taken into account [8] did not obtain with the psychosomatic diseases. DISCUSSION
In this study the relationship between physical and psychiatric disorder has been e x a m i n e d in t h e g e n e r a l p o p u l a t i o n w i t h the v a r i a b l e s b e i n g m e a s u r e d i n d e p e n d e n t l y o f e a c h o t h e r , op. cit. [2, 6]. W h i l e t h e d i s t r i b u t i o n o f M a j o r p s y c h o s o m a t i c d i s o r d e r s was significantly in excess in t h e p s y c h i a t r i c s a m p l e c o m p a r e d w i t h t h a t in the c o n t r o l it m u s t be b o r n e in m i n d t h a t c a r d i o v a s c u l a r d i s o r d e r s m a d e u p the b u l k o f these c o n d i t i o n s . C o n v e r s e l y , it was f o u n d t h a t f o r M i n o r p s y c h o s o m a t i c d i s o r d e r s t h e r e was a n excess in t h e c o n t r o l g r o u p a n d here, w i t h m e n s t r u a l d i s o r d e r s h i g h l y represented, the p r o b l e m o f p r e v i o u s surgical i n t e r f e r e n c e was e n c o u n t e r e d . T h e results i n d i c a t e t h e n e e d for c a u t i o u s a p p r a i s a l o f m e t h o d o l o g y in studies o f p s y c h o s o m a t i c disorder. T h u s , despite t h e large scale o f the s c r e e n i n g survey, the y i e l d o f so-called p s y c h o s o m a t i c d i s o r d e r s was small. I n o r d e r to i n c r e a s e t h e n u m b e r o f specific c o n d i t i o n s , a n d yet a v o i d s a m p l i n g a n d selection p r o b l e m s by c o n c e n t r a t i n g u p o n the g e n e r a l p o p u l a t i o n , a m u c h l a r g e r s u r v e y w o u l d h a v e t o be m o u n t e d . B e f o r e c o n s i d e r i n g a v e n t u r e o f such m a g n i t u d e it is essential to c o n s i d e r the definitions a n d i n t e r p r e t a t i o n s
Psychosomatic disorders in the community
385
of the term 'psychosomatic'. Currently it is used in the two senses expressed by the W.H.O. Committee and, in addition, as a description of a type of presentation in general practice. Each meaning should be examined separately. First, the term is employed in the sense that a physical condition is specifically stress-linked. This is a simple cause and effect model, akin to that for infectious disease, which does not fit the evidence for such chronic non-communicable disease as coronary heart disease which has had a variety of aetiological factors identified [18]. Each of these 'specific' psychosomatic disorders should be examined separately as has occurred with asthma [19, 20] and coronary heart disease [9] in order to identify the association between psychological factors and a given structural pathology. Second, the term is used to indicate a general psychophysiological propensity towards disease in some individuals. This is an ecological concept [21, 8] and is importanf in public health and preventative medicine. Here the epidemiological approach is appropriate in defining high risk groups and determining the factors which relate to vulnerability. Last, the term is used loosely to describe physical symptoms with no organic basis. While the commonest psychiatric presentation in general practice is an affective disorder with somatic symptoms this should not lead to the diagnosis of a psychosomatic state which subsumes physical pathology. This meaning should preferably not be used since it leads to confusion. Thus it would be preferable that the general practitioner recognised the affective disorder for what it was and gave the appropriate treatment, after what he thought to be justifiable investigation, rather than use the term 'psychosomatic' which implies both psychological and physical pathology. If further understanding of the role of psychological factors in the genesis or exacerbation of physical pathology is to be developed we must be clearly aware of the different definitions of the word 'psychosomatic' and, further, not use it to cover up clinical ignorance. Having clarified our meaning we can then investigate it after dealing with the issues of adequate instruments, population sampling and the incorporation of a prospective view into the design. REFERENCES 1. WORLDHEALTHORGANISATION.Psychosomatic disorders. W.H.O. Tech., Rep. Ser. No. 275. Geneva (1964). 2. COOPERB. The Epidemiological approach to psychosomatic medicine. J. Psychosom. Res. 8, 9 (1964). 3. RENNIET. A. C. and SROLEL. Social class prevalence and distribution of psychosomatic conditions in an urban population. Psychosom. Med. 18, 449 (1956). 4. SAINSBURYP. Psychosomatic disorders and neurosis in out-patients attending a general hospital. J. Psychosom. Res. 4, 261 (1960). 5. KREITMANN., PEARCEK. I. and RYLEA. The relationship of psychiatric, psychosomatic and organic illness in a general practice. Br. J. Psychiat. 112, 569 (1966). 6. RAWNSLEYK. Congruence of independent measures of psychiatric morbidity. J. Psychosom. Res. 10, 84 (1966). 7. SHEPHERDM., COOPERB., BROWNA. C. and KALTONG. W. Psychiatric Illness in General Practice. Oxford University Press, London (1966). 8. EASTWOOD M. R. and TREVELYAN M. H. The relationship between physical and psychiatric disorder. Psychol. Med. (in press). 9. EASTWOODM. R. and TREVELYANM. H. Stress and coronary heart disease. J. Psychosom. Res.
15, 289 (1971). 10. EASTWOODM. R. The Physical Status of Psychiatric Patients in General Practice. M.D. Thesis. University of Edinburgh (1970). Unpublished.
386
M . R . EASTWOOD and M. H. TREVELYAN
11. GOLDBERGD. P., COOPER B., EASTWOOD M. R., KEDWARD H. B. and SHEPHERD M. A standardised psychiatric interview for use in community surveys. Br. J. Prey. soc. Ned. 24, 18 (1970). 12. EASTWOODM. R. Screening for psychiatric disorder. Psychol. Ned. 1, 197 (1971). 13. BUCK C. and LAUGHTON W. B. Family patterns of illness: the effect of psychoneurosis in the parent upon illness in the child. Acta psychiat. Neurol. Scand. 34, 165 (1959). 14. College of General Practitioners. A classification o f Morbidity (1963). 15. KHOSLAT. and LOWE C. R. Indices of obesity derived from body weight and height. Br. J. Prey. soc. Ned. 21, 122 (1967). 16. HINKLE L. E. and WOLFF H. G. The nature of man's adaptation to his total environment and the relation of this to illness. Arch. intern. Ned. 99, 442 (1957). 17. HINKLE L. E., CHRISTENSON W. N., KANE F. D., OSTFELD A., THETFORD W. N. and WOLFF H. G. An investigation of the relation between life experience, personality characteristics and general susceptibility to illness. Psychosom. Ned. 20, 278 (1958). 18. MORRIS J. N., KAGAN A., PATTISON D. A., GARDNER M. J. and RAFFLE P. A. B. Incidence and prediction of ischaemic heart disease in London busmen. Lancet, 2, 553 (1966). 19. LEIGFI D. and MARLEY E. Bronchial Asthma. A Genetic, Population and Psychiatric Study. Pergamon Press, Oxford & London (1967). 20. ZEALLEYA. K., AITKEN R. C. B. and ROSENTHAL S. V. Asthma: a psychophysiological investigation. Proe. R. Soe. Ned. 64, 825 (1971). 21. LEIGH D. The form complete. The present state of psychosomatic medicine. Proc. R. Soc. Ned. 61, 375 (1968).
16, pp. 381 to 386. Pergamon Press. 1972. Printed in Great Bri[tain
PSYCHOSOMATIC DISORDERS IN THE COMMUNITY* M. R. EASTWOOD'~ a n d M. H. TREVELYAN~ (Received 25 May 1972)
THE W o r l d H e a l t h O r g a n i s a t i o n C o m m i t t e e on P s y c h o s o m a t i c D i s o r d e r s [1] has p o i n t e d o u t the " P s y c h o s o m a t i c P a r a d o x " wherein the t e r m has two meanings. Firstly, there is the holistic usage, e n d o r s e d by the C o m m i t t e e , which stresses t h a t m a n in health and disease functions as a p s y c h o s o m a t i c unit. Secondly, the t e r m is e m p l o y e d to describe disorders which occur specifically following stress u p o n a p a r t i c u l a r o r g a n system, e.g. in hypertension, peptic ulcer, ulcerative colitis a n d r h e u m a t o i d arthritis. The latter c o n c e p t was r e g a r d e d by the C o m m i t t e e as being controversial and, when " l i m i t e d to certain disorders the u n i t a r y a p p r o a c h to medicine is undermined, the m i n d - b o d y d i c h o t o m y is reaffirmed a n d a t e m p t a t i o n is offered to neglect p s y c h o l o g i c a l factors in some d i s o r d e r s a n d somatic factors in others". However, it was a g r e e d t h a t the s t a n d p o i n t s were c o m p l e m e n t a r y a n d the C o m m i t t e e suggested t h a t the e x p e r i m e n t a l evidence showed t h a t psychological stress was a p o t e n t p a t h o genic influence. Referring to e p i d e m i o l o g i c a l work, the C o m m i t t e e t h o u g h t the m a i n p r o b l e m s related to o b t a i n i n g p o p u l a t i o n samples a n d clear definitions o f p s y c h o s o m a t i c disorder. It was c o n s i d e r e d t h a t since p s y c h o n e u r o t i c s y m p t o m s a n d p s y c h o s o m a t i c d i s o r d e r s often occur in the same individual this indicates a general type o f p s y c h o p h y s i o l o g i c a l instability r a t h e r t h a n separate disorders o f either somatic or p s y c h o n e u r o t i c origin. C o o p e r [2] r e c o m m e n d e d t h a t psychological d i s t u r b a n c e a n d physical illness s h o u l d be r e g a r d e d as i n d e p e n d e n t variables a n d a search m a d e for statistical relationships between them. By this m e a n s a m o r e scientific f o r m u l a t i o n o f p s y c h o s o m a t i c disease m i g h t be reached. An epidemiological investigation of 11 psychosomatic disorders in terms of lifetime prevalence among an urban population aged 20-59 yr was carried out by Rennie and Stole [3]. They found the psychological dimension of tension-anxiety correlated with the majority of the somatic disorders. Sainsbury [4] investigated the relationship between psychosomatic disorders and neurosis in general out-patient clinics. A psychosomatic disorder was so described if the diagnosis had appeared in the works of at least two of six writers of recent works on psychosomatic medicine. Each patient, chosen at random, completed the Maudsley Personality Inventory. The condition from which the patient suffered was placed into one of four operationally defined groups: psychosomatic, possibly psychosomatic, control or neurotic. Patients in the psychosomatic and possibly psychosomatic groups were found to have significantly higher scores on neuroticism than the controls and the psychosomatic patients were considerably more introverted than the controls. It was considered that the results indicated that psychosomatic diseases were distinct entities and that there was some evidence to suggest that they were associated with either a dysthymic or an hysterical personality. Kreitman et aL [5] examined the relationship between psychiatric, psychosomatic and organic illness in a general practice population. The investigators found no positive correlations between those categories of illness and concluded that previous reports of a positive concordance were indicative not so much of a true association as the fact that the problem of self-referral among the patients had not been overcome. Rawnsley [6] has also emphasized the problems of case-selection in psychosomatic research. * From the Institute of Psychiatry, De Crespigny Park, Denmark Hill, London. t Present Address: Epidemiology Section, Clarke Institute of Psychiatry, 250 College St, Toronto, Ontario, Canada. :~Department of Clinical Epidemiology and Social Medicine, St. Thomas's Hospital, London. 381
382
M . R . EASTWOODand M. H. TREVELYAN
He thought that convincing evidence of a positive association between somatic pathology and psychological factors could only be answered when the detection of somatic pathology remained independent of the subjects' decision to seek advice and measures of somatic pathology were insulated from the effects of attitudes and response set. Shepherd et al. [7] in a psychiatric survey of general practices in London demonstrated a rate of 45'7 per 1000 at risk for psychophysiologic disorders and this compared reasonably well with the figure from a similar survey in Baltimore. They found that the 'psychiatric-associated' conditions ranged from psychosomatic disorders to physical conditions elaborated by psychological reactions. There were wide variations between practitioners regarding diagnostic reliability and it was evident that there was a spectrum of illness from classic psychoneuroses to the emotional concomitants of chronic physical disease. They argued the need for a nomenclature which would specify the psychological components in physical disease. T h e s t u d y t o b e d e s c r i b e d in this p a p e r was c o n c e r n e d w i t h testing the h y p o t h e t i c a l r e l a t i o n s h i p b e t w e e n p h y s i c a l a n d p s y c h i a t r i c disorder. It h a d the m e t h o d o l o g i c a l a d v a n t a g e o f t a k i n g a c r o s s - s e c t i o n a l v i e w o f t h e p a t i e n t s ' clinical state a n d u s e d o b j e c t i v e d a t a i n d e p e n d e n t l y c o l l e c t e d f r o m a r a n d o m l y selected g e n e r a l p r a c t i c e p o p u l a t i o n . T h e p h y s i c a l a n d p s y c h i a t r i c assessments w e r e m a d e q u i t e s e p a r a t e l y f r o m o n e a n o t h e r , b y different observers, at a h e a l t h s c r e e n i n g survey. A l t h o u g h t h e p a t i e n t s ' c o m p l a i n t s h a d to be t a k e n i n t o a c c o u n t f o r s o m e o f the d i a g n o s t i c assessm e n t s , t h e use o f strict c r i t e r i a f o r d i a g n o s i s r e d u c e d t h e p o t e n t i a l bias t o the m i n i m u m . It has b e e n s h o w n e l s e w h e r e t h a t t h e r e was a significant excess o f p h y s i c a l disease in t h e p s y c h i a t r i c as c o m p a r e d w i t h the c o n t r o l g r o u p ( E a s t w o o d a n d T r e v e l y a n , [8]) a n d t h a t this o c c u r r e d in p a r t i c u l a r w i t h c o r o n a r y h e a r t disease ( E a s t w o o d a n d T r e v e l y a n , [9]). I n this p a p e r w e are c o n c e r n e d w i t h the d i s t r i b u t i o n o f s o - c a l l e d p s y c h o s o m a t i c disorders. MATERIAL A N D METHODS The opportunity to carry out the study arose when the Department of Clinical Epidemiology and Social Medicine at St. Thomas's Hospital, London, carried out a screening survey in a South-East London borough. The purpose of this survey was to evaluate screening procedures. One of us (M.R.E.) participated in the psychiatric aspect of the screening, whereas the other (H.T.) was concerned with organisation and management of the screening procedure. A randomly determined half of all individuals aged 40-64 who were registered with a group practice in the borough were invited to attend the screening survey. The sampling was carried out by family. The names of couples and single people within the age-range were arranged alphabetically and every alternate pair or individual was selected. Couples with one partner outside the age range were accepted for the screening survey but only the spouse within the inclusive age-range was eligible for the study described because of the problem of obtaining matched controls. Of the 2223 sent an invitation (and if necessary a reminder) 1471, or 70 per cent, accepted and were screened. There were equal numbers of each sex, 90 per cent were married and 58 per cent were from the RegistrarGeneral's Social Class III (clerical and skilled manual occupations). The non-responders comprised 20 per cent who refused the invitation for screening and 10 per cent from whom no answer was received. Scrutiny of medical histories held on the Executive Council cards of the non-responders failed to demonstrate that their records indicated an excess proportion of neurotics as compared with the responders, although there was a trend for them to be older in two of the general practitioners' lists and to consult less frequently in three out of the five group practitioners' lists. The screening procedure consisted of three parts: 1. The completion of a questionnaire by each patient, with items related to both physical and psychiatric disorder. 2. Physical screening tests which covered the range of body systems and wherever necessary a clinical psychiatric interview. 3. A physical examination carried out by the patient's general practitioner two weeks later after all the initial screening results had been collated. The general practitioner also abstracted the past medical history from the patient's medical records and stated whether the conditions demonstrated at the survey were known to him. The psychiatric sample was identified using an initial screening instrument consisting of 20 items from the Cornell Medical Index known to discriminate between those with and those without a
Psychosomatic disorders in the community
383
psychiatric disorder in general practice (Eastwood [10]). Those who gave five or more positive responses were regarded as potential psychiatric cases and those with no positive responses as potential control cases. Clinical psychiatric interviews were then given to high scorers on the psychiatric items on the questionnaire (by M.R.E.), using a standardized interview schedule of known reliability (Goldberg et aL [11]). In order to obtain controls, a proportion of those with no positive responses on these items, and who demographically matched the high scorers, was also interviewed. The psychiatric sample was therefore matched for age, sex, marital status and Registrar-General's Classification of Social Class with a control group free from psychiatric disorder. The details of the psychiatric screening have been given elsewhere [12]. The final number of matched pairs, 37 male and 87 female, was 124. In order to compare the distribution of physical disease between the two groups it was necessary to classify the wide range of physical disease identified during the screening survey. A number of possible ways of doing this were considered: by organ system, duration, severity and whether acute or chronic. As, except for cardiovascular and respiratory disease, classification by organ system had limited application and as duration could not be measured accurately, it was decided to classify by severity. It seemed to us that most of the conditions identified would be chronic since acute illness would usually have precluded attendance at the screening survey. A n operational classification into 'Major' and 'Minor' disease was therefore devised. Any condition regarded as being liable to 'threaten or shorten life' was placed in the Major category and all others were placed in the Minor category. Similar classifications have been used elsewhere [5, 13]. Agreement was reached between four research psychiatrists, with considerable medical experience, on the categories to which each physical condition would be assigned. The diagnoses employed for the puposes of comparison were based upon those stated in the College of General Practitioners' short list of the International Classification of Disease [14]. Any physical condition which was included in the list compiled by Sainsbury [4] was called 'Psychosomatic'.
RESULTS The distribution of the conditions which occurred, from Sainsbury's list, was then compared for the psychiatric and control samples. This is shown in Table 1.
TABLE 1 . - - T H E
DISTRIBUTION OF PSYCHOSOMATIC DISEASE AMONG THE PSYCHIATRIC AND CONTROL GROUPS BY SEX
The psychosomatic disorders Major
Males Psychiatric Control
Females Psychiatric Control
Coronary heart disease Hypertension Asthma Diabetes Thyrotoxicosis Rheumatoid arthritis
11 3 0
Total Minor Chronic nasal infection Seborrhoeic dermatitis Psoriasis Eczema Prolapsed intervertebral disc Peptic ulcer Cervical erosion Menorrhagia/irregular menstruation Fungal infection
1
2
1
2
0 0 0
0 0 0
4 13 0
6 19 1
Total
3
3
21
33
37
37
87
87
Total patients
4 1 0
20 9 1
10 5 0
1
0
0
1
0 0
0 0
2 4
0 1
15
5
36
17
1 1
0 0
0 0
0 0
0 0 0
1 0 0
1 1 1
2 2 1
384
M . R . EASTWOODand M. H. TREVELYAN
Only two-thirds of the conditions in Sainsbury's list are included in the Table as the others did not occur in the samples examined. Obesity was excluded due to problems of definition but the mean and standard deviations of Quetelet's Index [15] did not differ between the psychiatric and control groups. Except for coronary heart disease and menstrual disorders the individual conditions were sparsely distributed. The distribution of Major psychosomatic disorder by individual is shown in Table 2. TABLE 2.
THE DISTRIBUTION OF MAJOR PSYCHOSOMATIC DISORDER BY INDIVIDUAL IN THE PSYCHIATRIC AND CONTROL GROUPS
Psychosomatic disorders by individual
None One Two Total Total patients Males Z ~ = Females Z 2 = Total Z z =
Male Psychiatric Control
%
%
64"9 35' 1 -100"0 37
86'5 13"5 -1000 37
Female Psychiatric Control
%
%
632 333 3"5 100'0 87
840 125 3"5 100'0 87
Total Psychiatric Control
%
%
63"7 33"9 2'4 1000 124
84-7 129 24 1000 124
4'6982; 1 d.f. p < 0'05 9"5746; 1 d.f.p<0'005 14"2366; 1 d.f.p<0001
The excess of Major psychosomatic disorder was significant for males, females and the tolal psychiatric sample. Whereas with men the difference was largely due to coronary heart disease, in the women the conditions were more broadly based, with an excess of coronary heart disease, hypertension, rheumatoid arthritis and the only cases of asthma and thyrotoxicosis. Minor psychosomatic disorders, of which there were only six conditions altogether among the males, were equally divided between the male psychiatric and control groups. There was a trend for the female control patients to have more Minor psychosomatic disorders than the psychiatric cases but not to a significant degree. This difference was largely due to an excess of gynaecological and menstrual disorders among the controls and could be partly explained by the fact that more in the psychiatric group had undergone the menopause, especially by hysterectomy, and this group, therefore, was less liable to menstrual disorders. The tendency for disease to cluster in some individuals, as described by Hinkle and Wolff [16, 17], which occurred when all diseases were taken into account [8] did not obtain with the psychosomatic diseases. DISCUSSION
In this study the relationship between physical and psychiatric disorder has been e x a m i n e d in t h e g e n e r a l p o p u l a t i o n w i t h the v a r i a b l e s b e i n g m e a s u r e d i n d e p e n d e n t l y o f e a c h o t h e r , op. cit. [2, 6]. W h i l e t h e d i s t r i b u t i o n o f M a j o r p s y c h o s o m a t i c d i s o r d e r s was significantly in excess in t h e p s y c h i a t r i c s a m p l e c o m p a r e d w i t h t h a t in the c o n t r o l it m u s t be b o r n e in m i n d t h a t c a r d i o v a s c u l a r d i s o r d e r s m a d e u p the b u l k o f these c o n d i t i o n s . C o n v e r s e l y , it was f o u n d t h a t f o r M i n o r p s y c h o s o m a t i c d i s o r d e r s t h e r e was a n excess in t h e c o n t r o l g r o u p a n d here, w i t h m e n s t r u a l d i s o r d e r s h i g h l y represented, the p r o b l e m o f p r e v i o u s surgical i n t e r f e r e n c e was e n c o u n t e r e d . T h e results i n d i c a t e t h e n e e d for c a u t i o u s a p p r a i s a l o f m e t h o d o l o g y in studies o f p s y c h o s o m a t i c disorder. T h u s , despite t h e large scale o f the s c r e e n i n g survey, the y i e l d o f so-called p s y c h o s o m a t i c d i s o r d e r s was small. I n o r d e r to i n c r e a s e t h e n u m b e r o f specific c o n d i t i o n s , a n d yet a v o i d s a m p l i n g a n d selection p r o b l e m s by c o n c e n t r a t i n g u p o n the g e n e r a l p o p u l a t i o n , a m u c h l a r g e r s u r v e y w o u l d h a v e t o be m o u n t e d . B e f o r e c o n s i d e r i n g a v e n t u r e o f such m a g n i t u d e it is essential to c o n s i d e r the definitions a n d i n t e r p r e t a t i o n s
Psychosomatic disorders in the community
385
of the term 'psychosomatic'. Currently it is used in the two senses expressed by the W.H.O. Committee and, in addition, as a description of a type of presentation in general practice. Each meaning should be examined separately. First, the term is employed in the sense that a physical condition is specifically stress-linked. This is a simple cause and effect model, akin to that for infectious disease, which does not fit the evidence for such chronic non-communicable disease as coronary heart disease which has had a variety of aetiological factors identified [18]. Each of these 'specific' psychosomatic disorders should be examined separately as has occurred with asthma [19, 20] and coronary heart disease [9] in order to identify the association between psychological factors and a given structural pathology. Second, the term is used to indicate a general psychophysiological propensity towards disease in some individuals. This is an ecological concept [21, 8] and is importanf in public health and preventative medicine. Here the epidemiological approach is appropriate in defining high risk groups and determining the factors which relate to vulnerability. Last, the term is used loosely to describe physical symptoms with no organic basis. While the commonest psychiatric presentation in general practice is an affective disorder with somatic symptoms this should not lead to the diagnosis of a psychosomatic state which subsumes physical pathology. This meaning should preferably not be used since it leads to confusion. Thus it would be preferable that the general practitioner recognised the affective disorder for what it was and gave the appropriate treatment, after what he thought to be justifiable investigation, rather than use the term 'psychosomatic' which implies both psychological and physical pathology. If further understanding of the role of psychological factors in the genesis or exacerbation of physical pathology is to be developed we must be clearly aware of the different definitions of the word 'psychosomatic' and, further, not use it to cover up clinical ignorance. Having clarified our meaning we can then investigate it after dealing with the issues of adequate instruments, population sampling and the incorporation of a prospective view into the design. REFERENCES 1. WORLDHEALTHORGANISATION.Psychosomatic disorders. W.H.O. Tech., Rep. Ser. No. 275. Geneva (1964). 2. COOPERB. The Epidemiological approach to psychosomatic medicine. J. Psychosom. Res. 8, 9 (1964). 3. RENNIET. A. C. and SROLEL. Social class prevalence and distribution of psychosomatic conditions in an urban population. Psychosom. Med. 18, 449 (1956). 4. SAINSBURYP. Psychosomatic disorders and neurosis in out-patients attending a general hospital. J. Psychosom. Res. 4, 261 (1960). 5. KREITMANN., PEARCEK. I. and RYLEA. The relationship of psychiatric, psychosomatic and organic illness in a general practice. Br. J. Psychiat. 112, 569 (1966). 6. RAWNSLEYK. Congruence of independent measures of psychiatric morbidity. J. Psychosom. Res. 10, 84 (1966). 7. SHEPHERDM., COOPERB., BROWNA. C. and KALTONG. W. Psychiatric Illness in General Practice. Oxford University Press, London (1966). 8. EASTWOOD M. R. and TREVELYAN M. H. The relationship between physical and psychiatric disorder. Psychol. Med. (in press). 9. EASTWOODM. R. and TREVELYANM. H. Stress and coronary heart disease. J. Psychosom. Res.
15, 289 (1971). 10. EASTWOODM. R. The Physical Status of Psychiatric Patients in General Practice. M.D. Thesis. University of Edinburgh (1970). Unpublished.
386
M . R . EASTWOOD and M. H. TREVELYAN
11. GOLDBERGD. P., COOPER B., EASTWOOD M. R., KEDWARD H. B. and SHEPHERD M. A standardised psychiatric interview for use in community surveys. Br. J. Prey. soc. Ned. 24, 18 (1970). 12. EASTWOODM. R. Screening for psychiatric disorder. Psychol. Ned. 1, 197 (1971). 13. BUCK C. and LAUGHTON W. B. Family patterns of illness: the effect of psychoneurosis in the parent upon illness in the child. Acta psychiat. Neurol. Scand. 34, 165 (1959). 14. College of General Practitioners. A classification o f Morbidity (1963). 15. KHOSLAT. and LOWE C. R. Indices of obesity derived from body weight and height. Br. J. Prey. soc. Ned. 21, 122 (1967). 16. HINKLE L. E. and WOLFF H. G. The nature of man's adaptation to his total environment and the relation of this to illness. Arch. intern. Ned. 99, 442 (1957). 17. HINKLE L. E., CHRISTENSON W. N., KANE F. D., OSTFELD A., THETFORD W. N. and WOLFF H. G. An investigation of the relation between life experience, personality characteristics and general susceptibility to illness. Psychosom. Ned. 20, 278 (1958). 18. MORRIS J. N., KAGAN A., PATTISON D. A., GARDNER M. J. and RAFFLE P. A. B. Incidence and prediction of ischaemic heart disease in London busmen. Lancet, 2, 553 (1966). 19. LEIGFI D. and MARLEY E. Bronchial Asthma. A Genetic, Population and Psychiatric Study. Pergamon Press, Oxford & London (1967). 20. ZEALLEYA. K., AITKEN R. C. B. and ROSENTHAL S. V. Asthma: a psychophysiological investigation. Proe. R. Soe. Ned. 64, 825 (1971). 21. LEIGH D. The form complete. The present state of psychosomatic medicine. Proc. R. Soc. Ned. 61, 375 (1968).