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A preliminary comparison of healthy elderly and young adults on the sunya revision of the psychosomatic symptom checklist
Journnl
ofPsvchosomatic
Research.
Vol.
34. No. 2, pp. 183-187.
1990.
0022-3999/90 $3.00 + .OO C 1990 Pergamon Press plc
Printed in Great Bntain.
A PRELIMINARY COMPARISON OF HEALTHY ELDERLY AND YOUNG ADULTS ON THE SUNYA REVISION OF THE PSYCHOSOMATIC SYMPTOM CHECKLIST MICHAEL J. ROSS,* PAUL J. HANDAL,* RAYMOND C. TAIT,t GEORGE T. GROSSBERG? and LINDA BRANDEBERRY* (Received 3 May 1989; accepted in revisedform
I September 1989)
Abstract-Elderly (n = 30) and young (n = 30) subjects, equated in terms of general physical health, education and depression, were compared in terms of Total, Frequency and Intensity scores on the psychosomatic symptom checklist (PSC). Elderly subjects scored significantly lower than young subjects for both PSC Total and PSC Intensity scores. These results call into question the practice of aggregating PSC data from age heterogeneous samples and indicate the importance of reporting all three PSC scores.
INTRODUCTION
THE SUNYA Revision of the psychosomatic symptom checklist (PSC) is a self-report measure of the frequency and intensity of 17 common psychosomatic complaints [ 11. The PSC has been employed in a number of recent investigations employing subjects representing a broad range of ages to discriminate psychosomatic from nonpsychosomatic populations and to measure treatment outcome. For example, Blanchard [2] studied subjects between the ages of 18 and 76 yrs and found PSC scores to reliably differentiate various stress-related disordered patients (i.e. irritable bowel syndrome, tension headache, migraine headache) from each other and from normal nonpatient controls. Additionally, researchers have reported significant pre- to post-changes in PSC scores of chronic headache patients aged 1948 yrs [3] and irritable bowel syndrome patients aged 23-76 yrs [4] following various forms of nonpharmacological, self-regulation based treatments (i.e. relaxation, biofeedback). Finally, Blanchard [5] used PSC scores as predictors of successful and nonsuccessful treatment outcome in chronic headache patients and/or relaxation therapies. (rangeage = 18-68 yrs) who received biofeedback The mean age of the subject groups in these studies ranged from 34.8 to 43.6 yrs and included subjects ranging in age from 18 to 76 despite the fact that the psychometric properties of the PSC were established on a heterogeneous sample of college students with a mean age of 18.6 yrs. In addition, investigators reported aggregated data (males and females combined) despite normative data on a college population [l] which demonstrated gender differences for PSC Total score. Finally, although the PSC yields three scores (Frequency, Intensity, Total), inve,stigators typically employ only PSC Total scores as the dependent measure [2,3,4].
*Saint Louis University. tSaint Louis University Medical Center. Address correspondence to: Michael J. Ross, Department N. Grand Boulevard, St Louis, MO 63103, U.S.A. 183
of Psychology,
Saint Louis University,
221
184
MICHAEL J. Ross
rt al.
Although the psychometric properties of the PSC were established on a young, college student population, recent research has employed older populations for which no normative data exist. In addition, recent research reports only Total PSC scores and omits Intensity and Frequency scores. The present study was designed as a preliminary investigation of the relationship of aging to PSC Intensity, Frequency. and Total scores. In order to ensure that potential differences were due to age, young and elderly subjects were equated in terms of general physical health, depression, and education. METHOD Subjects Sixty healthy subjects (30 young, 30 old), equally distributed in terms of gender, participated. group ranged in age from 62 to 79 (A4 age 67.8 yrs); the young group ranged in age from age 19.8 yrs).
The elderly 17 to 28 (M
The SUNYA Revision of the PSC is a 17-item, single-factor, self-report measure of psychosomatic symptoms with each item rated on a 0 4 scale for frequency (0 = not a problem, 4 = occurs daily) and intensity (0 = not a problem, 4 = extremely bothersome) [I]. The PSC yields three scores: Frequency (summation of frequency ratings), Intensity (summation of intensity ratings), and Total (summation of the cross-product of the frequency by intensity ratings). With college students. test-retest reliabilities for Total scores at l-week. 4-weeks, and R-weeks are 0.88. 0.84, and 0.80, respectively. Correlations of Frequency with Intensity scores among college populations are 0.85. Discriminant validity information has been provided by Attanasio [I]. The health screening report (HSR), used for initial screening of general physical and mental health, is a self-report measure consisting of 10 items generated by the authors. Eight items requested subjects to respond ‘yes’ or ‘no’ to indicate the presence or absence of symptoms. illness or disorder in the following system: cardiovascular, genitourinary. musculoskeletal. cognitive (including memory) and mood. One item requested subjects to list any active medical disorders and another item requested subjects to list all current medications and their dosages. Self-ratings of health involved subjects rating their ‘general health’ from 1 (excellent) to 9 (poor). The Beck depression inventory (BDI) consists of 21 items that assess both affective and cognitive symptoms of depression [6]. In a general adult sample, a split-half reliability of 0.93 was reported by Beck [7]. They also reported validity information in terms of a significant relationship between BDI scores and psychiatrists‘ ratings of depression. The BDI has been found to be reliable and valid with college student populations [8] and elderly populations [9]. The demographic questionnaire requested information concerning respondent age, gender, and education.
Elderly subjects were recruited by a newspaper advertisement requesting healthy elderly people to participate in a personality and health research study. Forty-six persons responded and were sent the HSR. the demographic questionnaire, and the self-rating of general health measure. The first fifteen males and fifteen females who reported no major physical or mental health problems on the HSR and who rated their overall health in the ‘good’ to ‘excellent’ range (i.e. I S)were selected to undergo a general medical examination by a physician specializing in gerontology. All thirty subjects’ HSR report of an absence of physical and mental health problems and their self-report of at least good general health were confirmed via the medical examination. Fifteen male and 15 female young subjects were randomly selected from a sample of 242 undergraduates who had an absence of physical health problems as reported on the HSR and who rated their general physical health in the ‘good’ to ‘excellent‘ range (i.e. I-S). In order to ensure comparability between the two age groups in terms of general health, education and depression, a multivariate analysis of variance (MANOVA) was performed: the results were not significant. Elderly and young subjects reported being healthy (M old 2.07. SD = 1.17; M young 2.07. SI) = 1.28).nondepressed (M old 6.27, SD = 5.04; M young 6.13, SI) = 5.47). and comparably educated (M old 13.20. SD = 2.76: M young 12.93. su = 1.20). These data suggest that the present sample of elderly subjects is atypically healthy both physically and mentally.
Psychosomatic
symptoms
and age
185
RESULTS
A 2 x 2 (gender, age) MANOVA was performed to determine the relationship between age, gender, and the three components of the PSC. Results revealed a significant main effect for age, F(3,54) = 5.52, p < 0.002. Neither the main effect of gender nor the age by gender interaction were significant. For age, follow-up univariate F tests revealed a significant (0.03) difference for PSC Total, F(l,56) = 4.96, with elderly significantly lower (M = 9.27, SD = 13.12) than young (M = 18.80, SD = 19.45). A significant (0.001) difference also was found for PSC Intensity, F(l,56) = 12.16, with elderly significantly lower (M = 4.83, SD = 4.53) than young (M = 10.57, SD = 7.78). No significant differences were found for PSC Frequency scores.
DISCUSSION
Comparisons of healthy young and elderly subjects revealed significant age-group differences for Intensity scores and Total scores on the PSC. The two subject groups did not differ significantly in terms of Frequency scores. These findings were based on samples of physically healthy, nondepressed elderly and college students who were similar in educational level. The fact that the two groups did not differ on two self-report measures of physical health (HSR and self-ratings) and that the older group was found to be in good health by physical examination suggests that group differences in health status can be ruled out as a rival explanation for the results. It appears that the significant difference between elderly and young subjects on the PSC Total score is accounted for by the significant difference between old and young subjects on the PSC Intensity score. Since PSC Total score is derived by multiplying item Intensity scores by item Frequency scores, it appears that the significantly lower Intensity scores of elderly subjects yielded the significant difference on Total. These findings reflect the need to analyze and report all three PSC scores, especially when using the PSC with populations for which normative data does not exist. By not analyzing and reporting all three scores, potential relationships within or between age groups and psychosomatic populations may remain undetected. Perhaps the most intriguing finding from the present study is that elderly persons scored significantly lower than young subjects on PSC Intensity scores. These findings cannot be attributed to differences in the frequency of psychosomatic complaints since no statistically significant difference was found between elderly and young subjects on PSC Frequency scores. Consistent with Costa and McCrae’s research on hypochondriasis among the elderly [lo], these findings contradict the widespread and stereotypic belief of increasing psychosomatic complaints with age. However, since our results are based on a highly selected (healthy, nondepressed) elderly sample, caution should be exercised in generalizing these findings to a heterogeneous sample of older persons because normative data does not exist other than for college students. The fact that elderly persons reported less intensity of psychosomatic symptoms than young persons may be accounted for by the process of adaptation and habituation. Given the opportunity for repeated exposure to the well-documented physiological and anatomical changes which accompany growing old [11], it is
186
MICHAEL J. Ross et al.
possible that our sample of elderly persons have adapted and habituated to these physical vicissitudes associated with aging. Again, whether or not this habituation and adaptation occurs in a more representative sample of elderly is unknown, since normative data exists only for representative younger populations. Our results lead to three specific recommendations regarding the use of the PSC. First, normative data on the PSC with a heterogeneous sample of elderly persons is needed to better understand the relationship of age to psychosomatic symptom reporting using the PSC. A similar recommendation for PSC normative data on non-college student populations has been made by Chibnall and Tait [12], who examined the psychometric properties of the PSC with chronic pain patients. Second, we recommend the utilization and reporting of all three PSC scores (Total, Frequency, Intensity) in investigations designed to assess psychosomatic disorders or to discriminate psychosomatic populations from each other and from nonpsychosomatic controls. By relying on Total PSC scores for assessment, significant information concerning psychosomatic complaints may remain undetected. Specifically, data related to the frequency or intensity of psychosomatic symptoms are lost which results in a less precise understanding of the presenting difficulties, i.e. whether intensity, frequency, or both are a significant contributor to the presenting psychosomatic complaint. Additionally, loss of these data precludes the possibility of planning and implementing interventions specific to either the frequency or intensity aspects of psychosomatic symptoms. Finally, we recommend that investigators report all three PSC scores in treatment studies which use the PSC as a dependent variable. By limiting PSC data to Total scores in treatment outcome studies, potential data concerning the active ingredients of intervention are lost, resulting in unnecessarily global (nonspecific) evaluation of treatment effects. Whether treatment affects intensity, frequency, or both remains unknown at the present time. Acknol~ledgemenrs-Preparation of this article was supported Grant from Saint Louis University to the first author.
by a Beaumont
Faculty
Development
REFERENCES 1. 2.
3.
4. 5.
ATTANASIO V, ANURASIK F, BLANCHARU EB, AREXA JG. Psychometric properties of the SUNYA Revision of the Psychosomatic Symptom Checklist. J Behac Med 1984; 7: 247-258. BLANCHARD EB, RADNITZ CL, EVANS DD, SCHWARZ SP, NEFF DF, GERARDI MA. Psychological comparisons of irritable bowel syndrome to chronic tension and migraine headache and nonpatient controls. Biofeedback Self Reg 1986; 11: 221-230. BLANCHARD EB, ANDRASIK F, APPELBAUM KA, EVANS DD, MYERS P, BAKRON KD. Three studies of the psychologic changes in chronic headache patients associated with biofeedback and relaxation therapies. P.yhosom Med 1986; 48: 73-83. BLANCHARLIEB, RADNITZC, SCHWARZ SP, NEFF DF, GERARDI MA. Psychological changes associated with self-regulatory treatments of irritable bowel syndrome. Eio/&dbuck SeJf Reg 1987; 12: 31~-37. BLANCHARD EB, ANDRASIK F, EVANS DD, NEFF DF, APPELBALJMKA, RODICHOK LD. Behavioral treatment of 250 chronic headache patients: A clinical replication series. Behar Ther 1985; 16: 308%327.
BECK AT. Depression: Clinical, Experimental, and Theoretical Aspecrs. New York: Harper and Row, 1967. BECK AT, WARD CH, MENDELSOXM, MOCK 1, ERBAUCH J. An inventory for measuring depression. Archs gen Psychiat
1961; 4: 53~63.
BUMBERRYW, OLIVER JM, MCCLURE JN. Validation of the Beck Depression Inventory in a university population using psychiatric estimate as the criterion. / consult C/in Psycho1 1978; 46: 150-155.
Psychosomatic 9. 10. Il. 12.
symptoms
and age
187
GALLAGHER D. The Beck Depression Inventory and older adults: Review of its development and utility. C1in Gerontol 1986; 5: 149-163. COSTA PT, MCCRAE RR. Hypochondriasis, neuroticism, and aging: When are somatic complaints unfounded? Am Psycho1 1985; 40: 19-28. EPSTEIN LJ. Aging. In: Review qf General Psychiatry (Edited by GOLDMAN HH). Norwalk: Appleton & Lange. CHIBNALL JT, TAUTRC. The Psychosomatic Symptom Checklist revisited: Reliability and validity in a chronic pain population. J Behav Med (In press).
ofPsvchosomatic
Research.
Vol.
34. No. 2, pp. 183-187.
1990.
0022-3999/90 $3.00 + .OO C 1990 Pergamon Press plc
Printed in Great Bntain.
A PRELIMINARY COMPARISON OF HEALTHY ELDERLY AND YOUNG ADULTS ON THE SUNYA REVISION OF THE PSYCHOSOMATIC SYMPTOM CHECKLIST MICHAEL J. ROSS,* PAUL J. HANDAL,* RAYMOND C. TAIT,t GEORGE T. GROSSBERG? and LINDA BRANDEBERRY* (Received 3 May 1989; accepted in revisedform
I September 1989)
Abstract-Elderly (n = 30) and young (n = 30) subjects, equated in terms of general physical health, education and depression, were compared in terms of Total, Frequency and Intensity scores on the psychosomatic symptom checklist (PSC). Elderly subjects scored significantly lower than young subjects for both PSC Total and PSC Intensity scores. These results call into question the practice of aggregating PSC data from age heterogeneous samples and indicate the importance of reporting all three PSC scores.
INTRODUCTION
THE SUNYA Revision of the psychosomatic symptom checklist (PSC) is a self-report measure of the frequency and intensity of 17 common psychosomatic complaints [ 11. The PSC has been employed in a number of recent investigations employing subjects representing a broad range of ages to discriminate psychosomatic from nonpsychosomatic populations and to measure treatment outcome. For example, Blanchard [2] studied subjects between the ages of 18 and 76 yrs and found PSC scores to reliably differentiate various stress-related disordered patients (i.e. irritable bowel syndrome, tension headache, migraine headache) from each other and from normal nonpatient controls. Additionally, researchers have reported significant pre- to post-changes in PSC scores of chronic headache patients aged 1948 yrs [3] and irritable bowel syndrome patients aged 23-76 yrs [4] following various forms of nonpharmacological, self-regulation based treatments (i.e. relaxation, biofeedback). Finally, Blanchard [5] used PSC scores as predictors of successful and nonsuccessful treatment outcome in chronic headache patients and/or relaxation therapies. (rangeage = 18-68 yrs) who received biofeedback The mean age of the subject groups in these studies ranged from 34.8 to 43.6 yrs and included subjects ranging in age from 18 to 76 despite the fact that the psychometric properties of the PSC were established on a heterogeneous sample of college students with a mean age of 18.6 yrs. In addition, investigators reported aggregated data (males and females combined) despite normative data on a college population [l] which demonstrated gender differences for PSC Total score. Finally, although the PSC yields three scores (Frequency, Intensity, Total), inve,stigators typically employ only PSC Total scores as the dependent measure [2,3,4].
*Saint Louis University. tSaint Louis University Medical Center. Address correspondence to: Michael J. Ross, Department N. Grand Boulevard, St Louis, MO 63103, U.S.A. 183
of Psychology,
Saint Louis University,
221
184
MICHAEL J. Ross
rt al.
Although the psychometric properties of the PSC were established on a young, college student population, recent research has employed older populations for which no normative data exist. In addition, recent research reports only Total PSC scores and omits Intensity and Frequency scores. The present study was designed as a preliminary investigation of the relationship of aging to PSC Intensity, Frequency. and Total scores. In order to ensure that potential differences were due to age, young and elderly subjects were equated in terms of general physical health, depression, and education. METHOD Subjects Sixty healthy subjects (30 young, 30 old), equally distributed in terms of gender, participated. group ranged in age from 62 to 79 (A4 age 67.8 yrs); the young group ranged in age from age 19.8 yrs).
The elderly 17 to 28 (M
The SUNYA Revision of the PSC is a 17-item, single-factor, self-report measure of psychosomatic symptoms with each item rated on a 0 4 scale for frequency (0 = not a problem, 4 = occurs daily) and intensity (0 = not a problem, 4 = extremely bothersome) [I]. The PSC yields three scores: Frequency (summation of frequency ratings), Intensity (summation of intensity ratings), and Total (summation of the cross-product of the frequency by intensity ratings). With college students. test-retest reliabilities for Total scores at l-week. 4-weeks, and R-weeks are 0.88. 0.84, and 0.80, respectively. Correlations of Frequency with Intensity scores among college populations are 0.85. Discriminant validity information has been provided by Attanasio [I]. The health screening report (HSR), used for initial screening of general physical and mental health, is a self-report measure consisting of 10 items generated by the authors. Eight items requested subjects to respond ‘yes’ or ‘no’ to indicate the presence or absence of symptoms. illness or disorder in the following system: cardiovascular, genitourinary. musculoskeletal. cognitive (including memory) and mood. One item requested subjects to list any active medical disorders and another item requested subjects to list all current medications and their dosages. Self-ratings of health involved subjects rating their ‘general health’ from 1 (excellent) to 9 (poor). The Beck depression inventory (BDI) consists of 21 items that assess both affective and cognitive symptoms of depression [6]. In a general adult sample, a split-half reliability of 0.93 was reported by Beck [7]. They also reported validity information in terms of a significant relationship between BDI scores and psychiatrists‘ ratings of depression. The BDI has been found to be reliable and valid with college student populations [8] and elderly populations [9]. The demographic questionnaire requested information concerning respondent age, gender, and education.
Elderly subjects were recruited by a newspaper advertisement requesting healthy elderly people to participate in a personality and health research study. Forty-six persons responded and were sent the HSR. the demographic questionnaire, and the self-rating of general health measure. The first fifteen males and fifteen females who reported no major physical or mental health problems on the HSR and who rated their overall health in the ‘good’ to ‘excellent’ range (i.e. I S)were selected to undergo a general medical examination by a physician specializing in gerontology. All thirty subjects’ HSR report of an absence of physical and mental health problems and their self-report of at least good general health were confirmed via the medical examination. Fifteen male and 15 female young subjects were randomly selected from a sample of 242 undergraduates who had an absence of physical health problems as reported on the HSR and who rated their general physical health in the ‘good’ to ‘excellent‘ range (i.e. I-S). In order to ensure comparability between the two age groups in terms of general health, education and depression, a multivariate analysis of variance (MANOVA) was performed: the results were not significant. Elderly and young subjects reported being healthy (M old 2.07. SD = 1.17; M young 2.07. SI) = 1.28).nondepressed (M old 6.27, SD = 5.04; M young 6.13, SI) = 5.47). and comparably educated (M old 13.20. SD = 2.76: M young 12.93. su = 1.20). These data suggest that the present sample of elderly subjects is atypically healthy both physically and mentally.
Psychosomatic
symptoms
and age
185
RESULTS
A 2 x 2 (gender, age) MANOVA was performed to determine the relationship between age, gender, and the three components of the PSC. Results revealed a significant main effect for age, F(3,54) = 5.52, p < 0.002. Neither the main effect of gender nor the age by gender interaction were significant. For age, follow-up univariate F tests revealed a significant (0.03) difference for PSC Total, F(l,56) = 4.96, with elderly significantly lower (M = 9.27, SD = 13.12) than young (M = 18.80, SD = 19.45). A significant (0.001) difference also was found for PSC Intensity, F(l,56) = 12.16, with elderly significantly lower (M = 4.83, SD = 4.53) than young (M = 10.57, SD = 7.78). No significant differences were found for PSC Frequency scores.
DISCUSSION
Comparisons of healthy young and elderly subjects revealed significant age-group differences for Intensity scores and Total scores on the PSC. The two subject groups did not differ significantly in terms of Frequency scores. These findings were based on samples of physically healthy, nondepressed elderly and college students who were similar in educational level. The fact that the two groups did not differ on two self-report measures of physical health (HSR and self-ratings) and that the older group was found to be in good health by physical examination suggests that group differences in health status can be ruled out as a rival explanation for the results. It appears that the significant difference between elderly and young subjects on the PSC Total score is accounted for by the significant difference between old and young subjects on the PSC Intensity score. Since PSC Total score is derived by multiplying item Intensity scores by item Frequency scores, it appears that the significantly lower Intensity scores of elderly subjects yielded the significant difference on Total. These findings reflect the need to analyze and report all three PSC scores, especially when using the PSC with populations for which normative data does not exist. By not analyzing and reporting all three scores, potential relationships within or between age groups and psychosomatic populations may remain undetected. Perhaps the most intriguing finding from the present study is that elderly persons scored significantly lower than young subjects on PSC Intensity scores. These findings cannot be attributed to differences in the frequency of psychosomatic complaints since no statistically significant difference was found between elderly and young subjects on PSC Frequency scores. Consistent with Costa and McCrae’s research on hypochondriasis among the elderly [lo], these findings contradict the widespread and stereotypic belief of increasing psychosomatic complaints with age. However, since our results are based on a highly selected (healthy, nondepressed) elderly sample, caution should be exercised in generalizing these findings to a heterogeneous sample of older persons because normative data does not exist other than for college students. The fact that elderly persons reported less intensity of psychosomatic symptoms than young persons may be accounted for by the process of adaptation and habituation. Given the opportunity for repeated exposure to the well-documented physiological and anatomical changes which accompany growing old [11], it is
186
MICHAEL J. Ross et al.
possible that our sample of elderly persons have adapted and habituated to these physical vicissitudes associated with aging. Again, whether or not this habituation and adaptation occurs in a more representative sample of elderly is unknown, since normative data exists only for representative younger populations. Our results lead to three specific recommendations regarding the use of the PSC. First, normative data on the PSC with a heterogeneous sample of elderly persons is needed to better understand the relationship of age to psychosomatic symptom reporting using the PSC. A similar recommendation for PSC normative data on non-college student populations has been made by Chibnall and Tait [12], who examined the psychometric properties of the PSC with chronic pain patients. Second, we recommend the utilization and reporting of all three PSC scores (Total, Frequency, Intensity) in investigations designed to assess psychosomatic disorders or to discriminate psychosomatic populations from each other and from nonpsychosomatic controls. By relying on Total PSC scores for assessment, significant information concerning psychosomatic complaints may remain undetected. Specifically, data related to the frequency or intensity of psychosomatic symptoms are lost which results in a less precise understanding of the presenting difficulties, i.e. whether intensity, frequency, or both are a significant contributor to the presenting psychosomatic complaint. Additionally, loss of these data precludes the possibility of planning and implementing interventions specific to either the frequency or intensity aspects of psychosomatic symptoms. Finally, we recommend that investigators report all three PSC scores in treatment studies which use the PSC as a dependent variable. By limiting PSC data to Total scores in treatment outcome studies, potential data concerning the active ingredients of intervention are lost, resulting in unnecessarily global (nonspecific) evaluation of treatment effects. Whether treatment affects intensity, frequency, or both remains unknown at the present time. Acknol~ledgemenrs-Preparation of this article was supported Grant from Saint Louis University to the first author.
by a Beaumont
Faculty
Development
REFERENCES 1. 2.
3.
4. 5.
ATTANASIO V, ANURASIK F, BLANCHARU EB, AREXA JG. Psychometric properties of the SUNYA Revision of the Psychosomatic Symptom Checklist. J Behac Med 1984; 7: 247-258. BLANCHARD EB, RADNITZ CL, EVANS DD, SCHWARZ SP, NEFF DF, GERARDI MA. Psychological comparisons of irritable bowel syndrome to chronic tension and migraine headache and nonpatient controls. Biofeedback Self Reg 1986; 11: 221-230. BLANCHARD EB, ANDRASIK F, APPELBAUM KA, EVANS DD, MYERS P, BAKRON KD. Three studies of the psychologic changes in chronic headache patients associated with biofeedback and relaxation therapies. P.yhosom Med 1986; 48: 73-83. BLANCHARLIEB, RADNITZC, SCHWARZ SP, NEFF DF, GERARDI MA. Psychological changes associated with self-regulatory treatments of irritable bowel syndrome. Eio/&dbuck SeJf Reg 1987; 12: 31~-37. BLANCHARD EB, ANDRASIK F, EVANS DD, NEFF DF, APPELBALJMKA, RODICHOK LD. Behavioral treatment of 250 chronic headache patients: A clinical replication series. Behar Ther 1985; 16: 308%327.
BECK AT. Depression: Clinical, Experimental, and Theoretical Aspecrs. New York: Harper and Row, 1967. BECK AT, WARD CH, MENDELSOXM, MOCK 1, ERBAUCH J. An inventory for measuring depression. Archs gen Psychiat
1961; 4: 53~63.
BUMBERRYW, OLIVER JM, MCCLURE JN. Validation of the Beck Depression Inventory in a university population using psychiatric estimate as the criterion. / consult C/in Psycho1 1978; 46: 150-155.
Psychosomatic 9. 10. Il. 12.
symptoms
and age
187
GALLAGHER D. The Beck Depression Inventory and older adults: Review of its development and utility. C1in Gerontol 1986; 5: 149-163. COSTA PT, MCCRAE RR. Hypochondriasis, neuroticism, and aging: When are somatic complaints unfounded? Am Psycho1 1985; 40: 19-28. EPSTEIN LJ. Aging. In: Review qf General Psychiatry (Edited by GOLDMAN HH). Norwalk: Appleton & Lange. CHIBNALL JT, TAUTRC. The Psychosomatic Symptom Checklist revisited: Reliability and validity in a chronic pain population. J Behav Med (In press).