Alexithymia, hypochondriacal beliefs, and psychological distress among frequent attenders in primary health care

Alexithymia, Hypochondriacal Beliefs, and Psychological Distress Among Frequent Attenders in Primary Health Care Simo Jyvfisj~irvi, Matti Joukamaa, Erkki V~iis~inen, Pekka Larivaara, Sirkka-Liisa Kivel~i, and Sirkka Kein~inen-Kiukaanniemi Frequent use of health services has been associated with such concepts as alexithymia, hypochondriasis, and psychological distress. The aim of this casecontrol study was firstly to assess whether alexithymia, hypochondriasis, and psychological distress are associated with frequent attendance and secondly to assess the gender differences of these associations in a primary health care setting. A sample of 304 frequent attenders (eight or more visits during I year), including all of the frequent attenders during 1994, and 304 randomly selected age- and sex-matched controls were selected. Half of the sample (every second individual selected in date-of-birth order) was invited for an interview, 113 frequent attenders and

A

RELATIVELY SMALL proportion of the population uses a disproportionately large share of health care services. These frequent attenders, who are also called "high utilizers" or "high or heavy users," usually complain of somatic symptoms although they commonly have more psychiatric disturbances than other patients, a-5 In previous studies, frequent use of health care services has been found to be associated with such concepts as alexithymia, 6 hypochondriasis,7,8 and psychological distress. 4,9 Since Sifneos 1° first coined the term "alexithymia"--having no words for feelings--more than two decades ago, this concept has been refined and developed. 11,~2Numerous studies have shown that alexithymia is associated with many different somatic diseases and psychiatric disorders. 12 Hypochondriasis, according to the DSM-IV classification, is a preoccupation of at least 6 months' duration with the fear of having or the idea that one has a serious disease based on a misinterpretation of bodily symptoms, despite appropriate medical

From the Department of Public Health Science and General Practice and Department of Psychiatry, University of Oulu, Oulu; Unit of General Practice, Oulu University Hospital, Oulu; and Oulainen Health Center, Oulainen, Finland. Supported by grants from the Emil Aaltonen Foundation and the Northern Ostrobothnia Hospital District. Address reprint requests to Simo Jyviisjdrvi, M.D., Health Center of Oulainen, PB 13, FIN-86300 Oulainen, Finland. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4004-0004510.00/0 292

107 controls completed a questionnaire during the interview. Alexithymia was measured with the Toronto

Alexithymia Scale-20 (TAS-20), hypochondriasis was screened with the Whiteley Index (Wl), and Symptom Checklist-36 (SCL-36) was used to determine psychological distress. We found a distinct gender difference in the associations of these characteristics with frequent attending. Significant associations of alexithymia, hypochondriasis, and psychological distress w i t h frequent attending were found among men, b u t not among women. Alexithymia, hypochondriasis, and psychological distress should be considered when treating frequent attenders, especially males.

Copyright© 1999by W.B. Saunders Company

evaluation and reassurance. This preoccupation causes clinically significant distress or impairment in some important areas of functioning. 13 The prevalence of hypochondriasis as a disorder varies from 0.4% to 14%, depending on the population surveyed and the methods u s e d . 14-16 The prevalence among males and females varies in different studies. 16,17 Hypochondriasis is associated with various somatic and psychological problems, especially depression. TM Hypochondriacal attitudes are associated with the use of medical services7,8 and "doctor-shopping behavior." 18 General practitioners (GPs) seldom recognize hypochondriasis 8,14 in an adequate manner, although they are aware of their patients' concerns and fears of disease and bodily preoccupation. It has been assumed that GPs are likely to ignore hypochondriasis because the word has a stigmatizing connotation. 19 There is increasing evidence that frequent attenders of health care have more psychological distress than other patients. 4,9 Several studies have proved that somatization is a common phenomenon among frequent attender, 2°,zl but it often remains undetected in primary health care. 22 Somatization may provide a link between psychological distress and frequent use of health services.4,19 Our study hypothesis was firstly that there is an association between frequent attendance and alexithymia, hypochondriasis, and psychological distress and secondly that the association is different among male and female frequent attenders in Finnish rural primary health care.

ComprehensivePsychiatry,Vol. 40, No. 4 (July/August), 1999: pp 292-298

ALEXITHYMIA AMONG FREQUENT ATTENDERS

293

METHOD The study is part of a larger research project on frequent attenders in the rural northern Finnish Health Center of Oulainen. 23 Oulainen is a small town with about 8,400 inhabitants, and the public primary health care facility (six GPs in a health center) is the primary way to access health care services. The flowchart of the study is presented in Fig 1. Patients who made eight or more visits to GPs during 1 year were defined as frequent attenders. 2,3 A sample including all frequent attenders aged 15 years or older during 1994 (304 patients) were selected from the annual statistics of the health center on the inhabitants of Oulalnen. For every frequent attender, one age- and sexmatched control (nonfrequent attender) was selected from the computerized patient register by random sampling. The control patients made fewer than eight visits to GPs in 1994.

I

A questionnaire was mailed to all frequent attenders and controls in 1995. It included questions about marital status, basic and vocational education, socioeconomic status, unemployment, retirement, housing, and family background. Socioeconomic status was defined according to Statistics Finland. 24 Classes 1 to 2 consisted of self-employed persons, class 3 upper-level nonmanual workers, class 4 lower-level nonmanual workers, class 5 manual workers, and classes 6 to 9 students, pensioners, and others. The response rate was 75.6% for frequent attenders and 74.0% for controls. Half of the original sample (every second subject selected from the database in date-of-birth order) was invited to participate in a personal interview. A nurse interviewed 113 frequent attenders and 107 controls in 1996, and the participation rates were 76.4% and 71.3%, respectively. The interview consisted of

>15 year old population in Oulainen 1994 N-6542

FAs(>=8N=304 visits in 1994) |1

|

i

age- andN=304 sex-matched |J

, / Analysisof ~e~licalrecordsand ~nt~ualstatistics ~/

,j I~

I

/ IP°stal quesUonnairl [ COs N=304 ]/

Answered ~

/ I

LF""==""'°°'°'! FAs ~

Answered i

tco'"==''<"0%,'

Selectionof everysecondin order. "~ Invitationfor interview. [ COs N=152 ]!

I

PersonalInterviewby a nurse. Questionnaireincl.TAS-20,SCL-36, | Wl Jl ~on-partlclpant$N=35~,< ~ ~on-participant. N=43.~ Fig1. Flowchartofthestudy. FAs,frequentattenders;COs, controlpatients.

I

,n-~,ewo.~.. .=113(,~ 4%)

ij

I~

'n"~iowodCO. .=107(740%) /j

294

JYVASJARVI ET AL

questions on family background, social support, and life events of the study groups. After the interview, every interviewee completed a short questionnaire including measures for alexithymia, hypochondriasis, and psychological distress. The lacking sociodemographic data were gathered afterward by a short inquiry. Alexithymia was measured using the Toronto Alexithymia Scale-20 (TAS-20). 25 The TAS-20 is a valid and reliable self-report instrument for assessing alexithymia. 26.27 It includes three factors, which reflect the three dimensions of alexithymia. Factor 1 reflects difficulties in identifying feelings and distinguishing them from the bodily sensations of emotion, factor 2 reflects difficulties in describing feelings to others, and factor 3 reflects an externally oriented mode of thinking. The factorial validity of the TAS-20 has been shown to be relevant. 25We used a cutoff score of 61 points or greater for alexithymia, while scores of 51 points or less implied nonalexithymia and scores between 51 and 61 were indeterminate. When dichotomizing for alexithymia, sum scores higher than 60 were regarded as alexithymic 11 (G.J. Taylor, personal communication, 1998). Hypochondriasis was screened using the Whiteley Index (WI) originally devised by Pilowsky.28 The sensitivity and specificity of the WI to discriminate between hypochondriacal and nonhypochondriacal patients are good, and the WI is reliable in screening for hypochondriasis among primary health care patients. 29,3° Scores of 6 points or higher were regarded as hypochondriacal when dichotomizing for hypochondriasis.8 To assess psychological distress among the frequent attenders, a 36-item version (SCL-36) of the Symptom Checklist-90 (SCL-90) was used. 31 SCL-36 includes subscales for assessing somatization, depression, and anxiety. A mean score of 1.55 or higher was considered to indicate psychological distress on dichotomous variables. 32 Chronic diseases, which were diagnosed in the medical records by GPs or based on hospital examinations, were classified according to ICD-9. If the patient had one or more diagnoses other than class V (psychiatric disorders) in the medical records, the patient was considered to have somatic morbidity. The SPSS for Windows (SPSS, Chicago, IL) software package was used in the statistical analyses, Chi-square tests were used for categorical data and t tests for continuous data. Mann-Whitney U tests were used for non-normally distributed continuous variables. The simultaneous association of alexithyrnia, hypochondriasis, and psychological distress with frequent attendance was analyzed by stepwise logistic regression analyses using the SAS software package (SAS Institute, Cary, NC).

RESULTS Altogether, 304 patients (4.7% of the population aged -> 15 years) appeared to be frequent attenders during the study year 1994. They included 206 (67.8%) women with a mean age (mean +__SD) of 51.1 +_ 18.3 years and 98 (32.2%) men with a mean age of 47.0 ___ 18.7 years; the men were significantly younger (P = .010). The frequent attenders had 3,334 encounters with GPs, which accounted for 23.5% of all visits made by patients within the

age group of 15 years or older. The control patients had 592 encounters, which is 4.2% of all GP contacts. The frequent attenders visited GPs a mean of 11.0 times during the year 1994 (median, 9.0), and the mean for the controls' visits was 2.0 (median, 1.0). 23 The female frequent attenders visited (mean; median) 10.8; 9.0 times and male frequent attenders 11.2; 9.0 times, while female control patients visited 2.0; 1.0 times and male controls 1.8; 1.0 times, during the year 1994. There were no significant differences in the mean age between interviewed frequent attenders and interviewed controls (Table 1). Similarly, differences in the mean age between men and women Table 1. Sociodemographic Characteristics of the Interviewed Frequent Attenders and Controls Frequent Attenders (n = 113) Characteristic Age, yr (mean _+ SD) Sex Female Male Marital status Unmarried Cohabiting Married Divorced Widowed Basic education Primary school 9-11 years 12 years Vocational education No education Lessthan 2years 2 years or more University degree Other education Occupational status Working Unemployed Disability pension Other pension Other Socioeconomic class Self-employed Upper-level nonmanual worker Lower-level nonmanual worker Manual worker Student, pensioner, other *ttest. tChi-square test.

No.

%

53.4 _+ 17.3

Controls (n = 107) No.

%

P

5.4 _+ 16.6 .393"

82 31

72.6 27.4

76 31

71.0 29.0

11 4 66 15 17 n = 70 35 8

9.7 3.5 58.4 13.3 15.0 113 61.9 31.0 7.1

15 8 64 5 15 n = 60 32 14

14.0 7.5 59,8 4.7 14.0 106 56.6 30.2 13.2

62 24 15 1 11 n = 34 8 24 37 10

54.9 21.2 13.3 0.9 9.7 113 30.1 7.1 21.2 32.7 8.8

45 30 16 7 9 n = 50 4 15 27 9

42.1 28.0 15.0 6.5 8.4 105 47.6 3.8 14.3 25.7 8.6

.800t .139t

.314t

.094t

.100t

.039t 11

9.7

10

9.3

1

0.9

11

10.3

34 61 6

30.1 54.0 5.3

31 52 3

29.0 48.6 2.8

A L E X I T H Y M I A A M O N G FREQUENT ATTENDERS

295

were nonsignificant in both study groups. The socioeconomic status of the interviewed frequent attenders was significantly lower than that of the interviewed controls, but there were no significant differences between the frequent attenders and controls with regard to sex, marital status, basic and vocational education, and occupational status. There were no significant differences between the interviewed subjects and the nonparticipants in attendance to GPs, marital status, basic education, or socioeconomic status. The mean age for the interviewed patients was 52.4 _ 17.0 years and for the nonparticipants 42.7 _+ 20.6 years (P < .001). There were more females in the interviewed group than among the nonparticipants (71.8% v 57.1%, P = .014). In the total interviewed sample, the frequent attenders had more hypochondriacal attitudes than the controls and were also more psychologically distressed. Somatization was more common among the frequent attenders than among the controls. There were no significant differences between the frequent attenders and controls with regard to alexithymia or the depression and anxiety subscales of psychological distress (Table 2). The male frequent attenders were more alexithymic than male control patients, whereas the corresponding difference between female frequent attenders and controls was nonsignificant. Male frequent attenders had more difficulties in identifying feelings (TAS-20 factor 1) than male control patients, but there were no significant differences between male frequent attenders and male controls on any other TAS factors. In women, no significant differ-

ences were found on the TAS factors between frequent attenders and controls. Male frequent attenders had significantly more hypochondriacal beliefs than male control patients. In women, the respective difference was nonsignificant. The male frequent attenders were more distressed than male controls with regard to both the SCL-36 total score and the scores for somatization, depression, and anxiety subscales, whereas the respective differences between female frequent attenders and controls were nonsignificant. Because frequent attendance had a statistically significant association with alexithymia, hypochondriacal beliefs, and psychological distress among men, a stepwise logistic regression analysis was performed. This analysis showed that only hypochondriacal attitudes were significantly associated with frequent attendance among male patients (P < .001). When adjusted for somatic morbidity, the association remained (P < .01). DISCUSSION The main finding of the study is, firstly that there was a significant association of frequent attendance with hypochondriasis and psychological distress but not with alexithymia among Finnish primary health care patients. Secondly, there was a distinct gender difference in the association of frequent attendance with hypochondriasis, psychological distress, and alexithymia. Among men, all three characteristics were associated with frequent attendance, while no such association existed among women.

Table 2. Alexithymia (TAS-2O total score and factors), Hypochondriacal Attitudes (Wl), and Psychological Distress (SCL-36 and factors) Among Frequent Attenders and Controls by Gender (mean _+ SD) Men Parameter

Frequent Attenders (n = 31)

Controls (n = 31)

Women P

Frequent Attenders (n = 82)

Controls (n = 76)

45.6 ± 10.5

45.0 ± 11.4

.661

12.8 ± 5.2

13.1 -+ 5.2

.656

P

TAS-20 Total score

51.7 -+ 11.0

46.1 -+ 8.7

.040

Factor 1

16.0 ± 6.1

11.2 ± 4.3

<.001

Factor 2

13.2 ÷ 4.3

12.4 ± 4.5

.558

11.1 _+ 4.3

11.6 -+ 4.6

.506

Factor 3

22.6 -+ 3.8

22.5 -+ 4.0

.761

21.8 +_ 5.0

20.4 ± 5.4

.168

5.8 ± 3.1

2.3 ± 1.8

<.001

3.3 ± 2.5

3.0 -+ 2.4

.422

Total score

56.3 -+ 13.6

44.5 _+ 13.8

<.001

50.2 ± 12.3

47.9 ± 11.8

.445

Somatization factor

20.9 ± 6.8

15.5 ± 4.7

<.001

18.7 ± 5.3

17.0 ± 5.4

.061

Depression factor

19.1 -+ 4.7

15.8 -+ 5.6

.001

17.2 _+ 5.3

17.9 ± 4.0

.157

A n x i e t y factor

11.3 -+ 3.0

9.5 ± 3.1

.006

9.6 ± 2.4

9.6 -+ 2.1

.849

Wl s u m points SCL-36

NOTE. P v a l u e s w e r e obtained by M a n n - W h i t n e y U-test.

296

The study group was a sample of the total population (15 years or older) of a rural town, and the selection was based on the number of visits to GPs recorded in the annual statistics of the health center. The cutoff point of eight visits per year as a criterion of frequent attendance can be discussed. The definition of frequent attender varies from one author to another. Some authors have proposed a number of visits varying from seven to 12 per year as a limit for frequent attendance. 1-3,33,34 Others have based their definition on the most frequently consulting decile of each age group. 35,36 Larivaara et al. 2,3 used eight visits as the criterion of frequent attendance in a study in a rural Finnish health center, and we used the same criterion. The cutoff point of eight visits for both genders does not take into consideration the baseline differences between the female and male frequency of seeking health care. 37 We found only slight differences between males and females among frequent attenders and controls when comparing the number of visits during 1994 in our study sample. The participation rate in the interviews was greater than 70%. The nonparticipants were younger and there were more men among them versus the interviewed group. It can be assumed that these differences caused no significant bias, because the participation rate was almost equal in the two study groups. In a previous Finnish study of primary health care patients in an urban setting, alexithymia was associated with the frequent use of health care, not directly but mediated by psychological distress. 6 Alexithymia correlates positively with depression, hypochondriasis, and somatization disorder, as well as a tendency to report physical symptoms, 384° which may partly explain its association with frequent attending. The connections between alexithymia and frequent use of health care have not been previously described separately for men and women. In this study, the only difference on the TAS-20 factors was on factor 1 (difficulties in identifying or describing feelings) between male frequent attenders and male controls. Hypochondriasis as determined by the WI was associated with frequent use of health care services in the total interviewed sample and in men, but not in women. There are previous findings indicating an association between the use of medical services and hypochondriacal attitudes, 7,8 but the studies

JYVASJARVI ET AL

have assessed neither frequent use nor sex-related differences. We also found an association between psychological distress measured by SCL-36 and frequent use of services. The association was definite on all three factors of SCL-36 (somatization, depression, and anxiety) among men, whereas no such association was found among women. Several other researchers have recently reported a correlation between psychological distress and frequent attendance in health services.4,9 In these studies, psychological distress has not been considered separately among men and women. The logistic regression model showed that only hypochondriasis was associated significantly with frequent attending among men when alexithymia, hypochondriasis, and psychological distress were considered simultaneously. After adjusting the somatic comorbidity, the association remained significant. The present results reveal some aspects of the portrait of male frequent attenders and support the findings of previous studies. On one hand, alexithymia may lead to the expression of emotional problems as somatic symptoms. 4° On the other hand, the bodily preoccupation of hypochondriacs and their "amplifying somatic style, ''19 i.e., sensitivity to normal bodily sensations, may enhance these symptoms. 15 Hypochondriacal beliefs may intensify the psychological distress, which may cause more somatic problems, 15 especially among alexithymic men, who have difficulties in identifying or describing subjective feelings. This may lead to a vicious cycle of distress and somatization. The portrait of female frequent attender remains obscure the concepts of alexithymia, hypochondriasis, and psychological distress did not explain their use of health care services in this study. The sex differences in the use of services, reporting of illness and symptoms, and answering in the interview study should be considered in interpreting the results. 37 What are the possibilities for GPs in primary health care to help frequent attender patients? GPs recognize their patients' psychiatric disorders poorly,4~,42 and somatization makes recognition even more difficult.22 Alexithymia may mask the psychological distress behind somatization. Hypochondriacal beliefs may lead GPs to unnecessary somatic examinations, which tend to make these patients' bodily preoccupation even worse. 2~

ALEXITHYMIA AMONG FREQUENT ATTENDERS

297

However, the majority of frequent attenders should be treated by GPs in primary health care, because frequent attenders usually do not feel a need for psychiatric therapy and GPs also have the skills to treat the frequent attenders' n u m e r o u s somatic diseases and functional somatic symptoms. 9 Some selected cases can be treated only in the psychiatric care system. There is not m u c h evidence-based research on the effectiveness of psychiatric care for hypochondriasis,l 5 and alexithymic persons are often unsuitable for traditional psycho therapy. 43 The medical care of somatizing patients should preferably be allocated to one primary care physician. 21 Short-term psychiatric consultation does not seem to i m p r o v e the psychiatric skills of GPs 44 or to reduce the use of services b y frequent attenders in primary health care. 45 This is a challenge for the basic medical education and the specialist training for general practice. In Finland, 2-year family m e d i c i n e training courses for GPs

have proved to develop their skills for treating psychosomatic and psychiatric disorders and to change their w o r k i n g style to be more system- and family-oriented and holistic. 46 In conclusion, alexithymia and hypochondriacal beliefs should be considered seriously w h e n frequent attenders, especially males, e n c o u n t e r GPs, because these characteristics enhance the psychological distress and somatization of these patients. The essential virtues of G P s - - a good and longstanding doctor-patient relationship and an understanding and c o m m i t m e n t to cooperation with p a t i e n t s - - a r e needed in treating frequent attender patients. Nevertheless, GPs need more training to improve the recognition and to adopt a patientcentered orientation in treating various problems of frequent attender patients in primary health care. Furthermore, more research is needed to evaluate alexithymia, hypochondriasis, and psychological distress a m o n g differently defined frequent attenders.

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