Patterns of illness behaviour in patients with intractable pain

Journal of PsychosomaticResearch, Vol. 19,pp.279 to 287. Pergamon Press, 1975.Printed in Great Britain

PATTERNS OF ILLNESS BEHAVIOUR IN PATIENTS WITH INTRACTABLE PAIN* I. PILOWSKY~ and N. D.

SPENCE

(Received 30 May 1975) Abstract-A 52 item self-administered questionnaire was constructed to assess illness behaviour. It was administered to 100 patients referred for the management of pain that had not responded adequately to conventional treatment. Responses were factor analysed using principal component analysis and rotated to orthogonal structure. Seven meaningful factors accounting for 63.3 % of the the variance were extracted and labelled as follows: general hypochondriacal factor, disease conviction factor, psychological vs somatic factor, affective inhibition factor, affective disturbance factor, denial factor and irritability factor. The significance of these dimensions of illness behaviour was discussed.

of illness behaviour was introduced by Mechanic [l] to refer to the ways in which symptoms may be differentially perceived, evaluated, and acted (or not acted) upon by different kinds of persons. Using this formulation as a starting point, Pilowsky [2] has proposed that a number of psychiatric syndromes (such as hypochondriasis, conversion reaction, neurasthenia, malingering, etc.) may be viewed as forms of ‘abnormal’ illness behaviour. In each case there is a discrepancy between the objective somatic pathology present and the patient’s response to it. The inappropriate reaction of the patient persists despite thorough medical examination, as well as careful explanation by the doctor of the nature of the patient’s symptoms and of their future management [3]. Although variables which may affect response to illness have been suggested [4] THE CONCEPT

TABLE1.-FACTOR ANALYTICSTUDIES DEALINGWITH ASPECTS OF ILLNESS BEHAVIOUR

*From the Department of Psychiatry, University of Adelaide, South Australia, 5001. tReprint requests to Professor I. Pilowsky, Department of Psychiatry, Royal Adelaide Hospital, Adelaide, 5000, Australia. 279

280

I. PILOWSKYand N. D. SPENCE

there has been little research aimed at delineating patterns of illness behaviour in patient groups. A number of factor analytic studies exist, however, that deal with inappropriate ways of perceiving and evaluating symptoms and that may provide some elementary dimensions of illness behaviour [.5-g]. The studies listed in Table 1 show a variety of factors extracted from several different populations. Not unexpectedly the number and nature of these factors changes from study to study depending on the characteristics of the patient sample, the types of variables used to differentiate patients, the method of rotation employed to simplify factors, and the criteria used to interpret factors and render them meaningful. The reliability of any dimensions of illness behaviour thus derived may be limited by these methodological considerations. The illness dimensions isolated so far by factor analysis are best suited then to describing differences within fairly specific populations of patients and cannot be easily generalized to other groups with different characteristics. If further factorial investigations are to prove useful, however, it would seem necessary that the following conditions should be fulfilled. First, patient populations should be heterogeneous enough to allow for a variety of reactions to illness. Second, it would seem desirable (at least initially) to concentrate on illness where these reactions are readily evoked. Finally, measures used to assess illness behaviour must be both convenient and acceptable to patients in a variety of clinical settings as well as being comprehensible in terms of their particular symptoms. The present study focusses on the illness behaviour of patients with intractable pain. Such a group would seem well suited to the exploration of this area since an individual’s experience of pain is determined by many perceptual, cognitive, affective, interpersonal and cultural variables [IO] such that a range of illness behaviour is likely in these patients. Furthermore, because these patients present with pain that has not responded adequately to conventional treatment their experience of illness is threatening enough (in terms of salience, duration, disruption, etc.) to demand attention and explanation on their part, and so to ensure that they have in fact reacted to and formed opinions about their illness. Using a special questionnaire the present study aimed to record and factor analyse the illness behaviour of patients with persistent pain, to discover what dimensions would differentiate such a sample, and to compare these factors with others identified by previous researchers. METHOD The study population comprised 100 unselected patients referred to the pain clinic or the psychiatric service of a large metropolitan hospital over a period of two years, for the management of intractable pain. In terms of Pilowsky’s [Z] definition these individuals may be regarded as manifesting “abnormal” illness behaviour. Ninety patients were referred to the clinic and 10 to the service. The sample consisted of 48 men and 52 women with a mean age of 49.1 yr (s.d. 14.9). The commonest site of nain was in the back, followed by the head and the abdomen. The average length of time that patients had experienced pain was 7.4 yr (s.d. 10.9). There was no significant relationship between age and duration of pain (r = 0.12). Only 20% of patients were judged to have major organic pathology associated with their pain, and only 27 patients suffered marked impairment due to pain. Table 2 provides a more detailed outline of the characteristics of the patient population. The pain clinic referred to is operated predominantly on an outpatient basis by a panel of specialists (including an anaesthetic, physician, neurologist, psychiatrist, social worker, and physiotherapist) which assesses the patient’s status in all aspects of health and adjustment. In conjunction with a routine psychiatric interview, each patient was asked to fill out a questionnaire “about you and your illness”. The results of the questionnaire, however, were not made known to the psychiatrist and did not form part of his report to the clinic.

281

Patterns of illness behaviour in patients with intractable pain TABLE

Length of illness

ATe


6wlyr

12

11

21-30yr

31-40yr

11 Site of pain

Head

21 urganic pathology

Minor

55' mlJ&:ment

&--CHARACTERISTICS

Mild 42

18 Chest

8 Moderate

25 Moderate 31

OF 100

PATIENTS

2-5yr

l-2yr

28

18 41-50yr

Sl-60yr

26

23

upper limbs

Back

8

27

WITH

INTRACTABLE

5-10yr

10

61-70yr 14 Abdominal

12

PAIN

JO-20yr

11

zo+yr

10

71+yr 8 Lower limbs 11

More than one area 13

Major

20 Marked 27

The self-report questionnaire is shown in Appendix 1. It consists of 52 Yes-No items which explore the illness behaviour of the patient plus three items requesting the patient’s age, sex and length of illness. The questions are largely not concerned with the presence or absence of physicial symptoms. They deal instead with the patient’s attitudes and feelings about his illness, his perception of the reactions of significant others in the environment (including his doctor’s) to himself and his illness, and the patient’s own view of his current psychosocial situation [2,3]. Fourteen of the items (marked by asterisk) were shown by Pilowsky [7] to discriminate between hypochondriacal and non-hypochondriacal patients. The data from the questionnaire was factor analysed using the method of principal factoring with iteration ill]. The resulting factors with eigenvalues > 1 were rotated to simple structure according to Kaiser’s varimax criterion. RESULTS The initial analysis yielded 18 unrotated factors with eigenvalues >l which accounted for 71.6% of the total variance. After rotation 12 factors remained with eigenvalues > 1 taking up 855 ‘A of the variance. It was decided that for a factor to be meaningful it should have at least 2 loadings greater than 0.40. Using this standard 7 factors were finally interpreted which accounted for 63.3 % of the variance. Their loadings are given in Table 3. Factors 6, 7, 8, 10 and 11, on the other hand, each showed only one item loading greater than @40 and these were on questions 42 (-0.63), 49 (-0.76), 23 (-0.67), 6 (-0.76) and 52 (-0.71) respectively. To aid interpretation composite factor scores were generated from the major loadings of the 7 factors. Scoring was arbitrarily weighted in the direction of abnormal or maladaptive illness behaviour as indicated in Table 3. High scores are thus indicative of inappropriate ways of perceiving, evaluating or acting upon one’s state of health. Table 4 shows the distribution of these scores on each factor. DISCUSSION

In the following section illness behaviour factors are characterized in terms of inappropriate item responses. This does not necessarily mean (as Table 4 reveals) that most patients actually manifest such deviant reactions, but certainly some do. Since factor analysis is based on the variance of the item responses rather than their mean values it is arbitrary whether or not one describes the resulting factors according

282

I. PILOWSKY andN.

D. SPENCE

TABLE 3.-QUESTIONNAIRE ITEMS LOADING GREATER THAN 0.40 ON 7 INTERPRETED FACTORS. A POSITIVE CORRELATION INDICATES AGREEMENT WITH AN ITEM. RESPONSES SHO‘WNINBRACKETS RECEIVED A SCORE OF +l. AN ARBITRARY CUT-OFF POINT OF 40 YR WAS USEDTODEFINEYOUNGERPATIENTSINFACTOR 12 Question number

Factor 1

Factor 2

2

-.%(Yes)

3

-.49(Yes)

Factor 3

Factor 4

Factor 5

Factor 9

4

.61(NO)

.48(No)

7 9

-.55(Yes)

10

-.68(Yes)

11

-.62(Yes) -.75(Yes)

12 .53(No)

16

-.rll(YS)

17 -.69(YeS)

18 20

-.57(Yes)

21

-.Sl(Yes)

22 24

.59

(No)

-.73(Yes) -.77(No)

27 29

-.71(Yes)

30

-.49(Yes) -.5J(No)

31 32

-.45(Yes)

35

.43(No) -.63(Yes)

36 37

-.55(Yes)

38

-.42(Yes)

41

-.48(Yes)

43

-.68(No)

44

-.55(Yes)

46

.56(No) -.52(Yesl

47 51

-.73(Yes) .62(<40yr)

we FfP23-it

Factor 12

24.8

10.0

7.6

6.8

6.5

4.3

3.3

variance _-____ Cumulative variance 24.8

34.8

to how most respondents emphasize the abnormal factor from the others.

42.4

49.2

55.7

60.0

63.3

score. The approach taken in the following discussion illness component in order more clearly to differentiate

is to each

Patterns of illness behaviour in patients with intractable pain TABLE

4.-DISTRIBUTION

E-actorscore

OF 100 PATIENTS WITH INTRACTABLE FACTOR SCORES

0

1

2

Factor 1 Factor 2

46

27

10

6

0

5

8

26

17

12

Factor 3

70

21

5

3

1

Factor 4 Factor 5

39

34

27

32

21

19

28

7

11

19

63

37

22

17

14

Factor

9

Factor 12

3

4

5

PAIN ON

283 7 COMPOSITE

6

7

8

3

4

2

3

1

1

23

9

10

The loading of variables in Factor 1 seems to indicate a general factor (accounting for 24.8 % of the variance) that is characterized by phobic concern about one’s state of health. The items suggest that this preoccupation with the possibility of disease is accompanied by a higher level of anxiety or arousal on the part of the patient. On only one item (‘more sensitive to pain’) does the patient agree that his physical health is actually worse than other People’s. This factor is very similar to the ‘disease phobia’ dimension described by Pilowsky [7] where the patient has some insight into his fears and asks anxiously for reassurance about conditions which he will often admit he does not really believe that he is suffering from. This general illness behaviour factor also points to an element of interpersonal alienation with the patient being easily annoyed or upset by the way other people react to his illness and envying their better health. This aspect of Factor 1 resembles a powerful factor (27.8% variance) described by Timmermans and Sternbach [8] characterized by a feeling of being out of control of one’s life, suspicion and anger towards others, blaming others for one’s difficulties, and attempts to manipulate and control others. However, whereas in their sample of pain patients this feeling of being different to others and not properly understood by them was commonly expressed, in the present study such alienation (where it exists) is only secondary to the patient’s phobic concern. Factor 2 seems to suggest a conviction of disease on the part of the patient with accompanying symptom preoccupation. It can be distinguished from the first factor by the adamant belief of the patient that he is seriously ill, even to the point of rejecting the doctor’s opinion. There is thus no suggesting by the patient that this conviction may be unjustified or unrealistic. Again, referring to Pilowsky’s [7] analysis, this factor seems to be a combination of two described in that study. One was a ‘bodily preoccupation’ factor in which the patient paid much attention to bodily sensations and feelings. The other was a ‘disease conviction’ factor characterized by a belief in the presence of serious pathology accompanied by a paranoid attitude to relatives and medical personnel which could perhaps be considered delusional. Factor 3 is a bipolar one which seems to contrast a somatic as opposed to a psychological perception of illness. This dimension is characterized by the attitude that the patient is somehow responsible for (and in fact deserves) his pain to the degree that he perceives himself to be in need of psychiatric rather than medical treatment. Such a reaction to illness, though it does not deny the existence of symptoms, attributes

284

I. PILOWSKYand N. D. SPENCE

them to psychological rather than organic causes. Factor 2, on the other hand, tends to emphasize the reverse explanation. The fourth factor is a fairly specific one which might be labelled affective inhibition. Its content is limited to two items describing difficulty in expressing personal feelings, especially negative ones, to others. That this dimension should be isolated is significant in view of the classic psychoanalytic formulation that unresolved anger and frustration are important precursors of psychosomatic disorder. Patients who are inhibited in terms of this factor may fail to assert themselves adequately in other areas of social functioning and so chronically experience frustration and the physiological arousal that invariably accompanies it. Such a tendency (and 27% of pain patients admit to being inhibited in expressing both personal and angry feelings) may be important in the aetiology of skeletomuscular pain, especially if tensing of the body is a characteristic reaction (flight or fight) to stress [12]. The loadings that constitute Factor 5 deal with acknowledgement of anxiety and depression. This dimension may be described as affective disturbance, and it is interesting to note that 28 ‘A of patients report being nervy, anxious, and depressed. Factor 5 is distinct from Factor 3 in that most pain patients would attribute such feelings to their illness rather than vice versa. Both Sternbach [lo] and Merskey and Spear [13] have documented the prevalence of depressed affect in patients with persistent pain. Factor 9 deals with presence of problems in one’s life. This is a meaningful dimension since patients who manifest so-called conversion reactions often refuse to admit that, apart from illness, they have any other difficulties in their lives. This factor might thus be labelled a denial factor. The final factor is characterized mainly by irritability, especially in younger patients. As Timmermans and Sternbach [S] found, it is these individuals who are more likely to react to their pain in an aggressive and angry way. This corresponds with the common clinical observation that in any situation young adults are more readily hostile than older people [14]. This factor can be distinguished from Factor 4 firstly because the latter lacks any age component, and secondly, because the tendency to bottle up feelings of anger is independent of their actual frequency.

CONCLUSION

The factor analytic approach utilized in this study has resulted in the isolation of seven meaningful dimensions of illness behaviour. Although these factors have been extracted from a specific patient population and thus describe different reactions to pain, it seems reasonable to anticipate that they may be successfully applied to other groups of patients. An actual description of the pain patient population (see Table 4) in terms of the factors described in the discussion, indicates that they show little phobic concern about their pain though they are convinced that they do have some sort of organic pathology and are preoccupied with their symptoms. Accordingly, they firmly reject any suggestion that their pain is the result of psychological factors. A substantial proportion of them admit, however, that they have difficulty in expressing their feelings (especially those of anger) to other people, a tendency which is not uncommon in patients with psychosomatic disorders. Many also describe themselves

Patterns of illness behaviour in patients with intractable pain

285

as being sad or anxious

though presumably they would explain this as being a result of their pain. Sternbach et al. [15] have observed the same type of attribution process in patients with chronic pain. Patients in the present study also showed a definite reluctance to acknowledge any life problems, a reaction which may be interpreted as conducive to conversion. Certainly it is consistent with the use of somatization as a coping style. Finally, some patients showed evidence of irritability and interpersonal friction (again attributed to their pain), a finding that supports Timmermans and Sternbach’s [S] contention that the management of some pain patients, especially younger ones, must utilize attempts at social integration and self-control just as much as relief from pain. REFERENCES 1. MECHANICD. The concept of illness behaviour. J. Chron. Dis. 15, 189 (1962). PILOWSKYI. Abnormal illness behaviour. Br. J. Med. Psychol. 42, 347 (1969). PILOWSKYI. The diagnosis of abnormal illness behaviour. Amt. N.Z. J. Psych&. MECHANICD. Medical Sociology. Free Press, New York (1968).

2. 3. 4. 5.

COMREYA. L. A factor analysis of items on the MMPI hypochondriasis Measurement

5,136

(1971).

scale. Educat. Psychol.

17, 568 (1957).

6. O’CONNORJ. P. and STEPICE. C. Some patterns of hypochondriasis. Educat. Psychol. Measurement 19, 363 (1959). 7. PILOWSKYI. Dimensions of hypochondriasis. Br. J. Psychiat. 113, 89 (1967). G. and STERNBACH R. A. Factors of human chronic pain: An analysis of personality 8. TIMMERMANS and pain reaction variables. Science 184, 806 (1974). 9. PRITCHARDM. J. Dimensions of illness behaviour in long term haemodialysis. J. Psychosom. Res. 18, 351 (1974). R. A. Pain: A Psychophysiological Analysis. Academic Press, New York (1968). 10. STERNBACH 11. NIE H. H., BENTD. H. and HULL C. H. Statistical Package for the Social Sciences. McGraw-Hill, New York (1970). 12. HOLMEST. H. and WOLFFH. G. Life situations, emotions, and backache. Res. Pub. Assoc. Res. Nerv. Ment. Dis. 29, 750 (1949).

13. MER~KEYH. and SPEAR F. G. Pain: Psychological and Psychiatric Aspects. Bailliere, Tindall and Cassell, London (1967). 14. FRIEDMANA. S. and GRAMICKS. A note on anger and aggression in old age. J. Geront. 18, 283 (1963). 15. STERNBACH R. A., WOLF S. R., MURPHYR. W. and AKESONW. H. Aspects of chronic low back pain. Psychosom. 14, 52 (1973).

I. PILOWSKY

286

andN.

D.SPENCE

APPENDIX 1 .-ILLNESSBEHAMOURQUESTIONNAIRESHOWINGITEMS(MARKEDBYASTERISK)SUCCESSFULLY USED BY PILOWSKY [7] TO DISCRIMINATE BETWEEN HYPOCHONDRIACAL AND NON-HYPOCHONDRIACAL PATIENTS. DETAILS OF THE PATIENT'S AGE, SEX, AND LENGTH OF ILLNESS WERE NOTED IN A SEPARATE FRONTISPIECE ATTACHED TOTHEQUESTIONNAIRE Here arc ~~rnf questions

about you and your

to indicate

to each question.

your answer

illness.

Circle

either

*1. Do you worry a lot about your health? *2. Do you think thcrf is something 3. Does your illness

interfere

YZS or NO

YE%

seriously

wrong with your body?YES

with your life a great deal?

YES

IUO NO NC

4. Are you easy to get on with when you are ill?

YES

NO

5. Does your family have a history

YES

NO

YES

NO

YES

NC

YES

NO

YES

NO

YES

NO

6. Do you think you are more 7. If the doctor You, would

of illness?

liable

to illness

than other people?

told you that he could find nothing

you believe

wrong with

him?

*8. Is it easy for you to forgot about yourself

and think about

all sorts of other things? *9. If you feel ill and someone better,

do you become

tells you that you arc lookincj

annoyed?

"10. Do you find that you are often happening

awarf of various

things

in your body?

11. Do you ever think of your illness something

you have done wrong

as a punishment

for YCS

in the past?

YES

12. Do you have trouble with your nerves? 13. If you feel ill or worried,

can you be easily

chcercd

up by YES

the doctor? 14. Do you think that other people

realize

what

NO

sick? 15..Does

it upset you to talk to the doctor

*16. Are you bothered 17. Does your

by many pains

illness

or friends

affect

*21. Are you afraid 22. Can you express

family

easily? as you?

to pain than other people?

of illness? your personal

feelings

easily

to other people?

feel sorry for you when you arc ill?

*24. Do you think that you worry people?

?I0

who has had the same illness

sensitive

NO

and aches?

a great deal?

19. Do you know anybody 20. Are you more

about your illness?

the way you get on with your

18. Do you find that you qct anxious

23. Do people

NO

its like to be

about your health

more

YCC

NO

YES

NO

YES

NO

YES

NO

YES

Pm

YES

NO

YES

IJO

YES

NO

than most

287

Patterns of illness behaviour in patients with intractable pain ;c,.

Do you Find that your illness

>'.. Lz ycu ex?cricnce

affects

L7. I:xiept for your illness, 28. Do you care whether

DO you

ha-d-o

f”Er

or not people

silly thoughts

can't get out of your mind, 31. Do you have any financial

is nothing

serious

37. Do you often

Ti R

NO

good health?YES which

think

take your illness?

about?

up your feelings?

suddenly

fall ill?

disease

is brought

to yor.r attention

television,

newspapers

or someone you know) do you worry

aboilt getting

illncr,s seriously

of your face or body?

*41. Do you find that you are bothered 42. Do you frequently

try to explain

by many

different

to others

think there is something

symptoms?

the matter

with your mind?

45. Arc you eating well? 46. Is your bad health

the biggest

difficulty

of your

life?

47. Do you find that you get sad easily? 48. Do you worry

or fuss over small details

a co-operative

*50. Do you often have the symptoms 51. Do you find that you gat angry 52. DO you have

any work problems?

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

patient? of a very easily?

YES

NO

YES

NO

YES

NO NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

that seem unimportant

to others? 49. Are you always

YES

how you are feeling?YES

43. Do you hive any family problems? 44. Do you

NO

are not taking your

enough?

40. Are I;OU upset by the appearance

NO

YES

(through the radio,

it yourself? that people

NO

YES

that you have got a

do you tend to bottle

*3'J. Do you get the feeling

YES

when he tells you

the possibility

that you might

NO

you

well?

zr,. whc:1 you are angry,

NO

NO

how hard you try?

the doctor

NO

YES

YES

you are sick?

about your health

YES

life?YES

illness?

35. Arc you sleeping

*3R.

in your

of other people's

for you to worry about

relations?

problems?

*33. Is it hard for you to believe there

realise

no matter

32. Arc ~071 upset by the way people

*34. Do you often worry

sexual illness?

do you have any problems

29. i)q you find that you get jealous 30.

your

a lot of pain with your

serious

disease?

YES

NO

YES

NO

YES

NO