Physician recognition of hypochondriacal patients

ELSEVIER

Psychiatry

and Primary Care

Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Wayne J. Katon, M.D., will publish informative research articles that address primary care-psychiatric issues.

Physician

Recognition

of Hypochondriacal

Patients

Terri T. Gerdes, M.D., Russell Noyes, Jr., M.D., Ro er G. Kathol, M.D., Brenda M. Philli s, M.D., Mary M. Fisher, M.A., hf .S.W., Maria Angeles & orcuende, M.D., and Stephen J. Yagla, M.S. To examineprimary care physicianrecognitionof hypochondriacal patients,weidentifieda seriesof suchpatients in a generalmedicineclinic using the Whiteley Index. Clinic physiciansmadeblind global rafings of severity of physical disease and unreasonable fear of illness(hypochondriasis) and completeda checklisfof somafizingcharacferisfics. Pufienf records wereauditedfor diagnoses, laboratoy tests,consulfations, and medicafionsprescribed.Twenty-nine(14%) of 210 patientsscoredabovean establishedcutoff on the Whifeley Index. Thesehypochondriacal patientswereratedby clinic physiciansas morehypochondriacaland were more offen given psychiatricdiagnoses. Also, clinic physiciansidentifiedmore somatizingfeaturesamonghypochondriacal patientsincluding their own reactionto them.Thisrecognitionof hypochondriacal characteristics may havecontributedto bettermanagement but may needfo be raisedto the diagnosticlevel for maximum benefit. Abstrad:

Introduction The identification of hypochondriasis in primary care is particularly important because of its prevalence (estimated at 4% to 9%) and associated morbidity [1,21. Hypochondriasis is the fear that one has or is about to develop serious or life-threatening illness, often accompanied by somatic symptoms that are misinterpreted [31. It causes impairment in physical functioning and work performance as well as unemployment and disability [4]. It is also assoDepartments of Psychiatry and Internal Medicine, University of Iowa, College of Medicine, Iowa City, Iowa Address reprint requests to: Russell Noyes Jr., M.D., Psychiatry Research, Medical Education Building, Iowa City, IA 52242.

106 ISSN 0163~8343/96/$15.00 SSDI 0163-8343(95)00122-O

ciated with increased nonproductive health care utilization 151. Promising drug and psychological treatments have been proposed and clinical trials are underway 16-81. However, if primary physicians are to manage and treat hypochondriacal patients effectively, they must first recognize them. In an earlier study, Beaber and Rodney 191 reported that primary care physicians fail to diagnose hypochondriasis and, as a result, patients with this disorder receive less than optimal care. The undiagnosed hypochondriacal patients that they studied received more laboratory tests and more often failed to return for scheduled appointments. The authors confirmed the impression of others that these patients make excessive use of health services yet are dissatisfied with the care they receive [5,10]. However, their study focused on diagnostic recognition. In an earlier investigation, we observed that primary physicians identify hypochondriacal patients, although not at a diagnostic level 141. In the present study, we examine this potentially important finding more closely. We hypothesized that physicians recognize hypochondriacal patients and that this recognition contributes to better medical care.

Methods Subjects

Subjects were 210 consecutive new patients attending a diagnostic clinic at the University of Iowa

General 655 Avenue

Hospital

Psychiatry 18,106-112, 1996 0 1996 Elsevier Science Inc. of the Americas, New York, NY 10010

Recognition of Hypnchontfriacal Hospitals and Clinics during a 2-month period beginning in January 1991. This outpatient medicine clinic is staffed by internal medicine residents and faculty. As in many tertiary health centers, some patients were referred by community physicians and others were self-referred for evaluation.

instruments Hypochondriacal symptoms were assessed by means of a modified version of the Whiteley Index [l]. This measure contains 14 items rated on 5-point linear scales (I- not at all to 5-a great deal). A cutoff score of 40 on the Whiteley was used to Identify hypochondriacal patients. This score was based on a previous study in which interview-diagnosed patients with hypochondriasis (range 37-69) were distinguished from controls (range 14-36) with only a single exception 141. Somatic symptoms were assessed by means of the Somatic Symptom Inventory ill]. This instrument contains 26 items also rated on 5-point linear scales (l-not at all to 5-a great deal). Patients also completed the Health History Questionnaire, Revised Version 1121. This instrument elicits demographic information and medical history; it includes psychiatric history (i.e., anxiety, depression, substance abuse, suicidal ideation) and current depressive symptoms. Clinic physicians rated how emotionally taxing or frustrating patients had been. They also rated severity of physical disease, extent to which disease explained symptoms, and unreasonable fear of illness (hypochondriasis). These ratings were made on 9-point ordinal scales ranging from absent or not at all (1) to extremely or completely (9). Clinic physicians also completed a checklist developed by one of the authors (RGK) [41. The checklist contained 13 items that required yes or no responses. These clinical features (i.e., atypical presentation, numerous unexplained somatic complaints, impairment out of proportion to disease, symptoms related to life stress, lack of response to usual treatment, compensation or litigation pending, numerous physicians involved, absence of objective findings, absence of abnormal laboratory findings, unstable lifestyle, family history of psychiatric illness, personal history of psychiatric illness, and presence of a psychiatric syndrome) are commonly used by clinicians to identify somatizing patients or patients whose somatic symptoms appear to be an expression of psychological distress.

Patients

Procedures As part of routine medicine clinic procedure, the Health History Questionnaire was mailed to patients along with information about their appointment. They were asked to bring the completed questionnaire with them to the clinic and 62% did so. On arrival, patients were asked to complete the Whiteley Index and Somatic Symptom Inventory. Medical records were subsequently audited by the authors to determine 1) diagnoses made,, 2) laboratory tests ordered, 3) consultations requested, and 4) medications prescribed. Psychiatric and functional somatic syndromes were identified and recorded along with the above information on record audit forms. Functional somatic syndromes were defined as irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and temporomandibular joint syndrome. Clinic physicians were asked to make global ratings and to complete a checklist of somatizing characteristics once they had finished their initial assessment of the patient. These ratings were made without knowledge of patient questionnaire responses.

Analyses Differences between hypochondriacal and nonhypochondriacal patients were examined using Student’s t-tests or, where values were not normally distributed, Wilcoxon two-sample tests. Differences between categorical variables were examined using chi-square tests or, where appropriate, Fisher’s exact tests. Where appropriate, the Cocharn-MantelHaenszel statistic was used to examine differences while controlling for severity of physical illness. Pearson correlation coefficients were used to examine relationships between continuous variables and level of hypochondriasis (Whiteley Index score) for all subjects combined. A logistic regression analysis was used to identify checklist items that best distinguished hypochondriacal and nnnhvpochondriacal subjects.

Results Two-hundred ten patients completed the Whiteley Index. Scores ranged from 14 to 69 and the mean (&SD) was 27.8 it 11.0. Twenty-nine (13.8%) patients scored 240 on the Whiteley Index and were regarded as being hypochondriacal. Table 1 shows the demographic profiles of hypochondriacal and nonhypochondriacal patients. Hypochondriacal pa-

307

T. T. Gerdes et al.

Table 1. Demographic and illness characteristics of hypochondriacal and nonhypochondriacal patients Hypochondriacal N = 29

Age (mean) Sex (female) Marital status (unmarried) Race (nonwhite) Education (mean) Whiteley Index Somatic Symptom Inventory

Nonhypochondriacal N=

168

P

43.1 + 20.6 62.1% 64.0% 15.4%

45.7 + 16.1 56.4% 40.3% 5.4%

12.1+ 2.3

13.2+ 3.0

ns

47.9 + 7.8 76.3 + 22.6

24.4 f 7.2 51.1 + 17.5

0.001 0.001

tients were less often married and less often white (trend). The difference in mean level of education was not statistically significant but there was a negative correlation between education and level of hypochondriasis (Whiteley Index) for all subjects (-0.27, p < 0.02). Hypochondriacal patients more often had a history of depression and they had more current depressive symptoms as reported on the Health History Questionnaire (Table 2). Also, more hypochondriacal patients had lifetime psychiatric diagnoses as recorded by examining physicians. However, there were few differences in the most common medical diagnoses between hypochondriacal and nonhypochondriacal patients. Current psychiatric syndromes were diagnosed in more hypochondriacal than nonhypochondriacal patients (27.6% vs 14.9%, p < 0.1) as were functional somatic syndromes (17.2% vs 9.5%, ns) although not to a statistically significant degree. Clinic physicians rated hypochondriacal patients as having more unreasonable fear of illness (hypochondriasis) than those without hypochondriasis

ns

0.E 0.10

and found hypochondriacal patients more emotionally taxing or frustrating than nonhypochondriacal patients (Table 3). Clinic physicians also rated hypochondriacal patients as having more somatizing characteristics than nonhypochondriacal patients (Table 4). Items showing significant differences were atypical presentation, unexplained somatic complaints, excessive impairment, lack of response to treatment, lack of objective findings, unstable lifestyle, personal psychiatric history, and current psychiatric syndrome. When a logistic regression analysis was done, the items that best distinguished hypochondriacal from nonhypochondriacal patients were unexplained somatic complaints (X2 = 7.16, p < 0.01) and excessive impairment (X2 = 6.67, p < 0.01). Odds ratios for these items were 7.1 and 9.4, respectively. More diagnoses were made and more medications were prescribed for hypochondriacal than for nonhypochondriacal patients (Table 5). These differences remained significant even when controlled for severity of physical disease. There were no dif-

Table 2. Psychiatric history of hypochondriacal and nonhypochondriacal patients obtained from Health History Questionnaire and medical record Hypochondriacal Anxiety (lifetime) Depression(lifetime) Alcohol abuse (current) Substanceabuse(current) Depressivesymptoms (current) Consideredsuicide (lifetime) Psychiatric diagnosis(lifetime) “Obtained by medical record audit.

108

Nonhypochondriacal

N = 29

N=

168

P

64.7% 64.7%

42.2% 28.9% 4.4% 6.8% 3.9 * 3.9 17.8% 22.7%

0.10 0.01

10.5% 10.0% 9.4 + 3.8 27.8% 46.4%

ns 0.onso01 OS?;

Recognition of Hypochondriacal

Table 3. Physician ratings of severity of physical disease and hypochondriasis among hypochondriacal and nonhypochondriacal patients Hypochondriacal N= 29

Global physician ratings Severity of disease Diseaseexplains symptoms Unreasonablefear of illness (hypochondria&) Emotionally taxing or frustrating

ferences between the number of laboratory

tests

and consultations ordered for hypochondriacal and nonhypochondriacal patients. Strong correlations were observed between hypochondriacal symptoms (Whiteley Index) and physician ratings of unreasonable fear of illness (r = 0.38, p < O.OOOl),and physician ratings of somatizing characteristics (r = 0.40, p < 0.0001) for the entire

Patients

-__

Nonhypochondriacal N=168

:’

4.1 + 1.7 5.2 r 2.0

3.5 * 1.5 5.6 T 2.7

O.I(i

3.7 rt 2.4 2.0 + 1.1

2.5 + 1.5 1.4kO.7

0.02

n3

0.02

driacal patients as having somatoform

disturbances

but rated them as more hypochondriacal and as having psychiatric and functional somatic syndromes more often. Also, these physicians identi-

fied more somatizing features among hypochondriacal patients including their own emotional reaction to them. These data confirm

our earlier

medicine clinic sample.

findings and show that recognition of hypochondriasis does indeed occur at a subdiagnostic level 141.

Discussion

This recognition of hypochondriacal tendencies may have contributed to better medical care in two

The first purpose of this study was to examine the ability of primary physicians to recognize hypochondriacal patients. We found that, although these physicians did not diagnose hypochondriasis, they nevertheless recognized patients with unreasonable fear of illness. They only labeled 2 of 29 hypochonTable 4. Percent of hypochondriacal

ways. First, it may have increased the diagnosis

of

psychiatric disorders. Twenty-eight percent of our hypochondriacal patients were given current psy-

chiatric diagnoses and 46% were identified as having had psychiatric disorders in their lifetime. These findings are consistent with those of Kirand nonhypochondriacal

patients as

having rated various somatizing characteristics by clinic physicians

Atypical presentation Unexplained somatic complaints Excessiveimpairment Psychosocialstressors Lack of responseto treatment Seeking compensation Numerous physicians involved Lack of objective findings Lack of laboratory abnormalities Unstable lifestyle Family psychiatric history Personalpsychiatric history Current psychiatric syndrome Total checklist score(mean)

Hypochondriacal N= 29 (%‘o)

Nonhypochondriacal

30.4 48.2 42.9 23.2 37.5 3.6 35.7 46.4 38.9 26.8 23.1 32.1 32.1 4.2 f 3.3

10.2 15.0 13.6 75.1 21.4

N=168

(5%)

v 0.05 0.00'1 0.01 0.;;

1.7 22.0 25.3 23.2 13.3 10.5 17.3 11.6 2.1 t 2.9

0253 0.01 0.10 0.05 0.10 0.05 0.05 0.01

“Mean number of items present.

109

T. T. Gerdes et al. Table 5. Indices of health care among hypochondriacal nonhypochondriacal patients Hypochondriacal N = 29

Diagnoses made Laboratory tests obtained Consultations requested Medications prescribed

3.3 3.1 1.3 2.8

mayer et al. [13] who reported that hypochondriacal worry increases the recognition of psychiatric distress. This is important because anxiety and depressive disorders are common in primary care yet often go undiagnosed. Second, our finding that the number of laboratory tests and consultation requests were about the same for hypochondriacal and nonhypochondriacal patients suggests that physicians limited their workup of hypochondriacal patients. Previous studies have shown that these patients receive repeated and unnecessary evaluations [9]. Hypochondriacal patients received more diagnoses, and more medications were prescribed for them than for nonhypochondriacal patients. These larger numbers do not necessarily reflect poor management of these patients. To some extent they resulted from more psychiatric disorders among the hypochondriacal patients. They also reflect a greater number of diagnoses patients had received and medications they had taken prior to their medicine clinic visit. Indeed, the number of diagnoses and medications may be another clue to somatization among primary care patients. However, optimal management calls for judicious reassessment and elimination of potentially harmful diagnoses and medications that have previously been given 1141. More attention to this aspect of hypochondriacal patient care may be needed. Using a checklist of somatizing characteristics, we showed that primary care physicians recognize hypochondriacal patients. However, the combination of items that in their hands was most discriminating-unexplained somatic complaints and excessive impairment--did not include the positive defining characteristics of hypochondriasis. Hypochondriacal patients have physical symptoms that are poorly explained by physical disease but they also have psychological symptoms. Using the checklist we showed that physician recognition is based mostly on inability to explain physical symp-

110

* + * r

1.3 2.6 2.2 2.5

and

Nonhypochondriacal N = 168 2.6 2.6 1.0 1.9

k it + k

1.6 2.2 1.2 2.1

P 0.01 ns

0:0”5

toms. This is consistent with physician emphasis on ruling out physical disease, but greater recognition might come from attention to psychological distress and psychological factors 1151. Physician frustration may also serve to increase recognition. Our data suggest this as do the findings of Lin et al. [161 and Hahn et al. 1171 who showed that somatizing patients evoke considerable physician frustration and distress. When we reviewed the medical records for information that might be used to increase recognition of hypochondriacal patients, we found a correlation of 0.60 between depressive symptoms, recorded on a health history questionnaire, and hypochondriacal symptoms. Barsky et al. 1181 observed a similar relationship between depressive and hypochondriacal symptoms among medical outpatients. Some patients have primary depressive and anxiety disorders and among them, hypochondriasis is an associated feature [191. Other hypochondriacal patients experience nonspecific psychological symptoms that may contribute to diagnostic recognition. Depressive and anxiety symptoms may be elicited by clinical interview or by screening instruments such as the General Health Questionnaire 1201. A score of 5 or more on this 2%item, self-administered measure indicates that a psychiatric disorder is likely present. This study has several important limitations. One is that patients were not diagnosed as having hypochondriasis but were identified as such by questionnaire. According to ratings made by clinic physicians, some of these patients had physical disease that might have disqualified them for such a diagnosis. In other instances, patients may have suffered from primary depression or had realistic bases for worry about serious illness. Also, the relatively small number of hypochondriacal patients may have weakened comparisons between groups. It is, of course, possible that the study of hypochondriasis itself influenced physician ratings. It may

Recognition of Hvpochomlriacal have raised their awareness or focused their attention on this particular condition. Also, patients who completed the Health History Questionnaire may have had more psychopathology than those who did not complete it. Diagnostic recognition of hypochondriasis was recently advanced by the development of structured interviews for use in primary care. These instruments, the PRIME-MD and the SDDS-PC, identify patients with common psychiatric disorders by means of two-step screening procedures 121,221. The PRIME-MD includes the somatoform disorders. A one-page questionnaire is first completed by the patient. Those who score above certain cutoffs are then interviewed briefly using a structured format. This takes less than 10 minutes and yields diagnoses that may change the approach to the patient. Both instruments have shown acceptable psychometric properties (i.e., reliability and validity) but widespread use may depend upon the ability of physicians to bill for their use or the availability of assistants to administer the interviews. The results of this study are encouraging. They show that physicians recognize hypochondriacal patients and, in so doing, may manage such patients more effectively. However, the recognition we speak of is subdiagnostic. We need to learn more about the evaluation process and what it might take to bring it to a diagnostic level. There are, of course, problems with the diagnosis of hypochondriasis. One is its pejorative nature and another is its uncertain prognostic value. Because controlled clinical trials have not been reported, treatment response and outcome are not yet known. Training programs for increasing awareness of somatoform disorders among primary care trainees have been described but real progress it apt to follow the development of effective treatments 1231.However, the effect of diagnosing hypochondriasis in primary care needs to be examined. The hypothesis that to do so may yield benefits in terms of patient care and satisfaction is certainly testable. We gratefirlly

acknowledge

tfze assistance

and cooperation of Imogene and clerical stuff of the which this study would not have been possible.

Barloon,

R.N., uzzd the entire medical, nursing,

medicine

clinzc. withoz(t

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