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Somatizing frequent attenders in primary health care
Journal of Psychosomatic Research 50 (2001) 185 ± 192
Somatizing frequent attenders in primary health care Simo JyvaÈsjaÈrvia,b,*, Matti Joukamaac,d, Erkki VaÈisaÈnenc,d, Pekka Larivaaraa, Sirkka-Liisa KivelaÈa,e, Sirkka KeinaÈnen-Kiukaanniemia a
Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland b Health Center of Oulainen, Oulainen, Finland c Department of Psychiatry, University of Oulu, Oulu, Finland d Department of Psychiatry, Oulu University Hospital, Oulu, Finland e Unit of General Practice, Oulu University Hospital, Oulu, Finland Received 15 November 1999; accepted 18 May 2000
Abstract Objective: The aim of this case-control study was to investigate the association of somatization with frequent attendance in primary health care. Methods: Frequent attenders in a health center (FAs) (N = 112) and age- and sex-matched controls (COs) (N = 105) constituted the study series. Data were collected from annual statistics, medical records, postal questionnaires and personal interviews. Psychological distress was assessed using Symptom Checklist-36 (SCL-36), alexithymia was measured with Toronto Alexithymia Scale-20 (TAS-20) and hypochondriasis was screened with Whiteley Index (WI). Results: About one-third of FAs were somatizers when a cut-off point of eight symptoms on the SCL-36 somatization subscale was used as a criterion. The significant
association of somatization with frequent attendance disappeared in multivariate analyses when adjusted for age, sex and chronic somatic illnesses. Hypochondriacal beliefs and psychiatric comorbidity were connected with FAs' somatization. Hypochondriacal beliefs explained somatizers' frequent attendance. A significant interaction effect between somatization and hypochondriacal beliefs was found when explaining frequent attendance. Conclusions: The results emphasize the need to use a comprehensive approach of somatization, including hypochondriacal beliefs, when treating somatizing FA patients in primary health care. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Alexithymia; Frequent attenders; Hypochondriasis; Primary health care; Somatization
Introduction Frequent attenders of health care (FAs) represent about 5 ±15% of the population, and they use approximately 20 ± 40% of health care services [1± 7]. According to previous studies, FAs represent a heterogeneous group of patients with a high prevalence of psychiatric disorders [8,9]. Somatization has been connected to the frequent use of health services [10 ± 13]. Lipowski [14] defined somatization as a tendency to experience and communicate somatic distress in response to psychosocial stress and to seek medical help for it. Because of the strict criteria of somatization disorder in DSM IV
* Corresponding author. Health Center of Oulainen, PO Box 13, FIN86301 Oulainen, Finland. Tel.: +358-8-4792563; fax: +358-8-4792529. E-mail address: [email protected] (S. JyvaÈsjaÈrvi).
[15], various other criteria have been developed for somatization, e.g. abridged somatization [16] and multisomatoform disorder [17]. Due to the differences in the criteria used to define somatization and the differences in the study populations, the prevalence of somatization varies from 1% to 12% [14,16,18,19]. Among primary care patients, the prevalence of somatization varies from 8% to 25% [17,19 ±23]. Somatizing patients are often involved in psychosocial difficulties [24], experience substantial distress [19] and show enhanced sensitivity to normal physical sensations [25 ±27]. Somatizing patients tend to use bodily symptoms to communicate, because they have difficulties to express their feelings in words. This emotional illiteracy or ``alexithymia'' [28] associates positively with somatization [29 ± 31]. Somatizing patients are characterized by abnormal illness behavior following the interpretation and attribution of bodily perceptions [14,19,24].
0022-3999/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 2 1 7 - 8
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Most somatizing patients have psychological symptoms, and half of them meet the criteria for a current psychiatric diagnosis, typically somatization disorder, hypochondriasis, depression or anxiety [14,19,20,32± 34]. Somatizing patients prefer general medical services to mental health services [35] and use hospital services excessively [36,37]. Somatization goes frequently unrecognized [18], and physicians tend to focus on excluding organic etiologies through multiple tests and procedures [18,38], which causes the health care system a great deal of expenses [11,14,27,39]. Somatizing patients are challenging for the physician ± patient relationship, and physicians are commonly frustrated by such patients [10,24,27]. There are some studies concerning somatization among FA patients. Katon et al. [10] found somatization to be a continuum: increasing severity of somatic symptoms indicated increasing distress, disability and maladaptive illness behavior. Portegijs et al. [12] found the prevalence of somatization to be 45% in a group of FA patients in general practice. In Finland, previous projects have revealed somatization to be connected with frequent attendance in primary health care. Psychosomatic disease or symptoms were found to be the chief problem of 57% of FA patients [5,40]. About onefifth of FAs were classified as chronically somatizing patients in an urban Finnish health centre [13]. In the first substudy of the present project, we found FAs to prefer somatic reasons for encounter more often than could have been expected on the basis of their psychiatric morbidity [7]. In the second substudy of this project, significant associations of alexithymia, hypochondriasis and psychological distress, including somatization, with frequent attendance were found among men [41]. In this substudy, we hypothesized somatization to be associated with frequent attendance in Finnish primary health care. Secondly, we aimed to clarify how somatizing FAs differ from nonsomatizing FA patients and, finally, to identify the factors connected with somatizers' frequent use of health care services. Method Subjects The study is part of a larger research project dealing with FAs in the rural northern Finnish Health Center of Oulainen [7,41]. Oulainen is a small town with about 8400 inhabitants. The public primary health care facility, including six physicians (GPs) in the health center, is the primary way to access health care services. The patients who had made eight or more visits to GPs during the year 1994 were defined as FAs [5,40]. All the FAs aged 15 years or older during the year 1994 (304 patients) were drawn from the annual statistics of the health center, which cover the inhabitants of Oulainen. For each
FA, one age- and sex-matched control patient (CO) (nonfrequent attender) was drawn from the computerized patient register by random sampling. The control patients had made fewer than eight visits to GPs in 1994. Procedure The study design has been described in detail earlier [7,41]. For every FA and CO patient, the following data were obtained from the annual statistics of the health center: the number of visits to GPs, the number of inpatient episodes in the health center and the number of inpatient days in the health center during the study year 1994. Furthermore, the annual statistics of the Northern Ostrobothnia Hospital District were used to determine the utilization of specialized care: inpatient days in general and mental hospitals, number of inpatient episodes in general and mental hospitals and outpatient visits to general and mental hospitals. The medical records of the FAs and COs were examined by one member of the research team (S.J.), and the following data were collected. The chronic diseases diagnosed by GPs or based on hospital records were classified according to the International Classification of Diseases, 9th revision (ICD-9). The visits to GPs' surgeries during the years 1992 and 1993 were also counted. The total numbers of laboratory visits, laboratory tests, X-ray visits and X-ray films during the year 1994 were counted. Two FA patients and six COs had moved from the municipality, and their medical records were not available. A postal questionnaire was sent to all FAs and COs in 1995. The response rate was 75.6% for FAs and 74.0% for COs. The questionnaire included questions about the patients' sociodemographic backgrounds and living conditions. Socioeconomic status was defined according to Statistics Finland (Central Statistical Office of Finland) [42]. Self-rated health was assessed using a Likert-type scale. Half of the original sample (every second subject selected from the original study population in the date of birth order) were invited to participate in a personal interview. A nurse interviewed 113 FAs and 107 COs in 1996, and the participation rates were 76.4% and 71.3%, respectively. There were no significant differences between the interviewed subjects and the nonparticipants in their medical attendance, marital status, basic education or socioeconomic status. The mean age (S.D.) of the interviewed patients was 52.4 (17.0) years and that of the nonparticipants 42.7 (20.6) years ( P < .001). There were more females in the interviewed group than among the nonparticipants (71.8% vs. 57.1%, P =.014). After the interview, every interviewee filled in a short questionnaire including measures of psychological distress, alexithymia and hypochondriacal beliefs. Feelings of loneliness were elicited with a Likert-type question. To assess psychological distress, a 36-item version (SCL-36) of the Symptom Checklist-90 (SCL-90) was used [43]. SCL-36
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includes subscales for assessing somatization, depression, and anxiety. A mean score equal to or higher than 1.55 per item was considered to indicate psychological distress on the dichotomous variables [44]. We used a cut-off point of eight symptoms or more out of the 12 symptoms on the SCL-36 somatization scale as a criterion for somatization. Altogether 112 of the interviewed FAs and 106 of the interviewed COs filled in the SCL-36. Alexithymia was measured using the Toronto Alexithymia Scale-20 (TAS-20) [45]. TAS-20 is a valid and reliable self-report instrument for assessing alexithymia [46,47]. 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
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of emotion, while Factor 2 reflects difficulties in describing feelings to others, and Factor 3 reflects an externally oriented mode of thinking. The factorial validity of TAS20 has been shown to be relevant [46]. When dichotomizing for alexithymia, sumscores higher than 60 were regarded as alexithymic [30]. Hypochondriasis was screened using the Whiteley Index (WI) originally devised by Pilowsky [48]. The sensitivity and specificity of WI to discriminate between hypochondriacal and nonhypochondriacal patients are good, and WI is reliable in screening for hypochondriasis among primary health care patients [49,50]. Scores equal to or higher than 6 points were regarded as hypochondriacal when dichotomizing for hypochondriasis [51].
Table 1 Sociodemographic characteristics of somatizing and nonsomatizing frequent attenders and controls FAs Variable Age (years) (mean (S.D.)) Sex Female
COs
Somatizers (n = 32)
Nonsomatizers (n = 80)
59.3 (15.6)
50.8 (17.5)
20 (62.5)
62 (77.5)
Marital status Unmarried Cohabiting Married Divorced Widowed
4 1 16 5 6
(12.5) (3.1) (50.0) (15.6) (18.8)
7 (8.8) 3 (3.8) 49 (61.3) 10 (12.5) 11 (13.8)
Basic education Primary school 9 ± 11 years 12 years
27 (84.4) 5 (15.6) 0 (0.0)
42 (52.5) 30 (37.5) 8 (10.0)
Vocational training No training Less than 2 years 2 years or more University degree Other training
21 6 1 0 4
Occupational status Working Unemployed Disability pension Other pension Other
5 (15.6) 2 (6.3) 13 (40.6) 11 (34.4) 1 (3.1)
Socioeconomic classificationc 1 ± 2 Self-employed persons 3 Upper-level nonmanual workers 4 Lower-level nonmanual workers 5 Manual workers 6 ± 9 Students, pensioners, others
5 0 6 18 3
(65.6) (18.8) (3.1) (0.0) (12.5)
(15.6) (0.0) (18.8) (56.3) (9.4)
40 18 14 1 7
(50.0) (22.5) (17.5) (1.3) (8.8)
29 (36.3) 6 (7.5) 11 (13.8) 25 (31.3) 9 (11.3) 6 1 28 42 3
(7.5) (1.3) (35.0) (52.5) (3.8)
Somatizers (n = 17)
Nonsomatizers (n = 89)
P
a
62.6 (15.0)
49.1 (16.1)
.003a
.105b
14 (82.4)
61 (68.5)
.251b
P .020
.845b
.005b
.246b
.013b
.255b
The values are numbers (percentages) unless otherwise indicated. a P values by t tests. b P values by chi-square tests. c Socioeconomic classification according to Statistic Finland: Classification of occupations 1980.
0 1 11 0 5
(0.0) (5.9) (64.7) (0.0) (29.4)
14 (82.4) 1 (5.9) 2 (11.8)
14 7 53 5 10
(15.7) (7.9) (59.6) (5.6) (11.2)
45 (51.1) 31 (35.2) 12 (13.6)
11 1 1 1 2
(64.7) (5.9) (5.9) (5.9) (11.8)
34 29 13 6 7
5 0 3 8 1
(29.4) (0.0) (17.6) (47.1) (5.9)
45 (51.7) 4 (4.6) 11 (12.6) 19 (21.8) 8 (9.2)
1 1 3 11 1
(5.9) (5.9) (17.6) (64.7) (5.9)
9 10 27 41 2
(38.2) (32.6) (14.6) (6.7) (7.9)
(10.1) (11.2) (30.3) (46.1) (2.2)
.131b
.038b
.177b
.186b
.532b
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In the second phase, when explaining the differences between somatizing FAs and nonsomatizing FAs, we used somatization as a dependent variable. Psychiatric diagnosis, alexithymia and hypochondriacal beliefs were considered as potential predictors of FAs' somatization. In further analyses, we tried to find out which factors explain somatizers' frequent attendance. Using frequent attendance as a dependent variable, we included psychiatric illness, alexithymia and hypochondriacal beliefs in the logistic regression model as potential explanatory variables. We also considered the interaction effect between hypochondriacal beliefs and somatization when explaining frequent attendance. In this analysis, we used frequent attendance as a dependent variable and hypochondriacal beliefs and somatization and their interaction term as explanatory factors.
Statistical analyses In the statistical analyses, the SPSS for Windows statistical software package was used. Chi-square tests or Fisher's exact tests were used for between-group comparisons of categorical data and t tests for normally distributed continuous data. Mann ± Whitney U tests were used for nonnormally distributed continuous variables. Multivariate logistic regression analyses were used to calculate the adjusted odds ratio (OR) and its 95% confidence intervals (CI). The selection of explanatory variables to model was conducted by stepwise method. When considering the association between somatization and frequent attendance, we used frequent attendance as a dependent variable and somatization, as hypothesized, as an explanatory variable in logistic regression analyses.
Table 2 Chronic illnesses, self-rated health, loneliness and use of health care services among somatizing and nonsomatizing frequent attenders and controls FAs Variable
COs
Somatizers (n = 32)
Nonsomatizers (n = 80)
P
Somatizers (n = 17)
Nonsomatizers (n = 88)
P
Diagnosed illnesses Number of chronic illnesses Having chronic somatic illness (%) Having a psychiatric diagnosis (%)
2.9 (1.5) 30 (93.8) 10 (31.3)
1.9 (1.4) 68 (85.0) 7 (8.8)
.001 .343a .007a
2.1 (1.6) 15 (88.2) 1 (5.9)
1.1 (1.5) 49 (55.7) 4 (4.5)
.006 .013a 1.000a
Self rated health and loneliness Self rated health good (%) Living alone (%) Feelings of lonelines often (%)
1 (3.4) 9 (31.0) 10 (31.3)
24 (37.5) 9 (13.6) 10 (12.5)
< .001a .046b .019b
2 (14.3) 2 (14.3) 9 (52.9)
45 (61.6) 15 (20.3) 16 (18.0)
.002a 1.000a .004a
7.2 (5.2) 7.1 (5.8)
6.1 (4.1) 5.8 (4.0)
.309 .355
4.0 (4.2) 3.4 (3.1)
2.4 (2.3) 2.2 (2.2)
.124 .146
.874 .692 .792 .374
2.1 8.2 0.8 2.4
1.3 4.7 0.4 1.4
.098 .100 .015 .031
Visits to GP's surgeries Number of visits 1992 Number of visits 1993 Use of laboratory and X-rayc Number of laboratory visits Number of laboratory tests Number of X-ray visits Number of X-ray films
4.9 18.6 1.6 3.0
(4.8) (16.7) (1.8) (4.5)
4.9 15.8 1.5 3.2
(4.7) (11.6) (1.3) (3.7)
(2.4) (9.7) (0.8) (3.4)
(1.9) (7.3) (0.8) (2.4)
Use of health center (HC) ward c care HC ward care episodes Days in HC ward
0.7 (1.2) 4.0 (8.7)
0.2 (0.5) 0.7 (2.4)
.003 .003
0.1 (0.2) 0.1 (0.5)
0.04 (0.3) 0.2 (1.8)
.418 .410
Use of general hospitalized carec Hospitalized care episodes Days in hospital care Outpatient visits
1.4 (1.3) 6.5 (9.4) 9.5 (10.6)
0.8 (1.2) 3.2 (6.8) 6.4 (8.6)
.008 .010 .019
0.4 (0.6) 2.7 (6.5) 3.0 (3.0)
0.3 (0.9) 2.3 (11.6) 1.9 (3.2)
.404 .325 .037
Use of mental health carec Mental hospitalized care episodes Days in mental hospital care Mental outpatient visits
0.03 (0.2) 0.5 (2.7) 2.8 (10.2)
0.0 (0.0) 0.0 (0.0) 1.2 (5.9)
.114 .114 .535
0.0 (0.0) 0.0 (0.0) 0.0 (0.0)
0.01 (0.1) 0.2 (1.8) 0.01 (0.1)
.662 .662 .662
The values are means (S.D.) unless otherwise indicated. P values by Mann ± Whitney U tests. a P values by Fisher's exact test. b P values by chi-square tests. c Use of health care services during 1994.
S. JyvaÈsjaÈrvi et al. / Journal of Psychosomatic Research 50 (2001) 185±192
Preliminary analyses revealed that chronic somatic illnesses associated significantly with both frequent attendance and somatization and chronic somatic illness as dichotomized variable together with age and sex were considered as confounding variables in the logistic regression analyses. Results The 304 FA patients included 206 (67.8%) women, whose mean age (S.D.) was 51.1 (18.3) years, and 98 (32.2%) men with a mean age of 47.0 (18.7) years; the men were thus significantly younger ( P =.010). The interviewed FAs included 32 (28.6%) somatizing patients, while 17 (16.0%) of the CO patients were somatizers ( P =.027). The mean age (S.D.) of the interviewed FAs was 53.4 (17.3) years and that of COs 51.4 (16.6) years, the difference being insignificant ( P =.393). Somatization was connected with frequent attendance in logistic regression analysis adjusted with age and sex (OR 2.1; 95% CI 1.04± 4.1; P =.039), but when chronic somatic illness was included in the analysis as a confounding variable, the association appeared to be nonsignificant. Differences between somatizing and nonsomatizing FA patients Somatizing FA patients were significantly older and they had significantly lower basic education than nonsomatizing FA patients (Table 1). Occupational status differed significantly between somatizing and nonsomatizing FAs; more somatizing FAs were on disability pension and fewer were working.
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FA somatizers had more chronic illnesses, and they rated their health as poorer than nonsomatizing FAs. About onethird of somatizing FAs lived alone, and the same proportion of them had feelings of loneliness (Table 2). Somatizing FAs used inpatient services of the health center four to five times more than nonsomatizing FAs (Table 2). Use of secondary care was similarly 1.5 ±2-fold among somatizing FAs compared to nonsomatizing FAs. The number of laboratory visits and tests and the use of Xray were quite equal in the two FA groups. FA somatizers were significantly more distressed and alexithymic than nonsomatizing FAs (Table 3). Hypochondriacal beliefs were more common among somatizing FAs than nonsomatizing FAs. In multivariate analyses among FAs, the hypochondriacal beliefs associated significantly with FAs' somatization after adjustment for age, sex and chronic somatic illness (OR 4.3; 95% CI 1.5 ±11.8; P =.005). Similarly, diagnosed psychiatric illness were connected with FAs' somatization (OR 4.3; 95% CI 1.3 ± 14.0; P =.014). Alexithymia did not associate with FAs' somatization in multivariate analysis. Differences between somatizing FA patients and somatizing CO patients There were no significant differences in sociodemographic background between the FA somatizers and CO somatizers (Table 1). The differences in chronic illness, psychiatric morbidity, self-rated health, living alone and feelings of loneliness between the somatizing groups were nonsignificant (Table 2). Psychological distress scores and alexithymia scores were equal between FA and CO somatizers. Somatizing
Table 3 Psychological distress, alexithymia and hypochondriacal beliefs among somatizing and nonsomatizing frequent attenders and controls FAs
COs
Variable
Somatizers (n = 32)
Nonsomatizers (n = 80)
P
Somatizers (n = 17)
Nonsomatizers (n = 89)
P
Psychological distress (SCL-36) Anxiety Depression Total psychological distress
12.2 (2.8) 20.6 (6.4) 65.0 (11.5)
9.2 (2.1) 16.6 (4.2) 46.6 (9.1)
< .001 .001 < .001
11.2 (2.8) 22.0 (4.7) 63.2 (10.0)
9.3 (2.2) 16.3 (3.9) 43.8 (10.3)
< .001 < .001 < .001
Alexithymia Alexithymia (TAS-20 sum) TAS-20 factor 1 TAS-20 factor 2 TAS-20 factor 3
50.8 15.8 12.2 22.7
(10.5) (6.0) (3.7) (4.4)
45.6 (10.6) 12.6 (4.9) 11.3 (4.6) 21.7 (4.9)
.034 .004 .155 .234
51.5 16.2 13.3 22.1
(11.5) (6.5) (5.5) (5.2)
44.2 (10.2) 12.0 (4.4) 11.6 (4.4) 20.7 (5.0)
.008 .009 .185 .253
Hypochondriacal beliefs Hypochondriacal beliefs (WI sum) Having hypochondriacal beliefs (%)
5.8 (2.6) 17 (53.1%)
3.2 (2.6) 16 (20.0%)
< .001 .001a
3.7 (2.3) 2 (11.8%)
2.6 (2.2) 10 (11.2%)
.042 1.000b
Values are means (S.D.) unless otherwise indicated P values by Mann ± Whitney U tests. a P value by chi-square test. b P value by Fisher's exact test.
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FAs had significantly more commonly hypochondriacal beliefs than somatizing CO patients ( P =.006) (Table 3). In multivariate analyses among somatizing patients, hypochondriacal beliefs were significantly associated with somatizers' frequent attendance when controlling for age, sex and chronic somatic illness (OR 8.5; 95% CI 1.5 ± 50.1; P =.018), while psychiatric illness and alexithymia were not significant predictors of somatizers' frequent attendance. When modelling frequent attendance, the interaction effect between somatization and hypochondriacal beliefs was evident. The interaction effect was statistically significant even after adjustment for age, sex and chronic somatic illness and including the main effect term of somatization in the model (OR for interaction term 10.7; 95% CI 2.0 ± 56.9; P =.006). Discussion The main finding of the study was, firstly, that almost one-third of primary care FAs were somatizers, the prevalence of somatization among FAs being significantly higher than among COs. The significant connection between somatization and frequent attendance disappeared when chronic somatic illness was considered as a confounding variable. Secondly, hypochondriacal beliefs and psychiatric illness were connected with FAs' somatization. Thirdly, hypochondriacal beliefs explained somatizing patients' frequent attendance after controlling for age, sex and chronic somatic illness. When explaining frequent attendance in primary health care, a significant interaction effect between somatization and hypochondriacal beliefs was found. The connection of somatization with frequent attendance was confirmed in bivariate analyses, and the finding is in line with some earlier reports [10,12,41]. We found a significant confounding effect of chronic somatic illness on the association of somatization with frequent use of health care services, contrary to the findings of Katon et al. [10]. One-third of FA somatizers had a psychiatric diagnosis according to the medical records, and psychiatric comorbidity associated significantly with FAs' somatization in multivariate analyses. This finding is in line with the findings of Katon et al. [10] and Portegijs et al. [12]. Our study confirmed the previous assumption of the role of hypochondriasis as an explanatory factor of frequent attendance [52]. Hypochondriacal beliefs combined with numerous functional somatic symptoms are strong predictors of frequent attendance in primary health care; this was a new finding. We found almost one-third of the interviewed FAs to be somatizers, while significantly fewer somatizers were found among the CO patients. The prevalence of somatization has varied in previous studies from 20% to 45%, mainly due to differences in the criteria of somatization and the populations [10,12,13].
FA somatizers were older than nonsomatizing FAs and the basic education of somatizing FAs was lower than that of nonsomatizing FAs. These finding were contradictory to those of Katon et al. [10] and Portegijs et al. [12]. The differences in sociodemographic characteristics did not explain somatizers' frequent attendance. Somatizing FAs used general hospital services significantly more than nonsomatizing FAs, but their use of mental health care was not noticeably more frequent, although they had marked psychiatric comorbidity. These results were in agreement with the earlier somatization study findings [35 ± 37]. FA somatizers rated their health as poor and reported feelings of loneliness. Previous studies have shown somatizers' self-rated health [10] and quality of life [17] to be poorer than other patients' self-rated health and quality of life. We found FA somatizing patients to be more distressed than nonsomatizing FA patients, and somatization among FAs also associated with anxiety and depression; these findings are in line with the earlier results on somatizing patients [12,32,33,53]. Alexithymia associated with somatization in bivariate analyses, confirming the results of some earlier studies [29 ± 31,54]; this connection has not been reported earlier among FAs. However, psychological distress and alexithymia did not explain somatizers' frequent attendance. The study group was a sample of primary health care patients (15 years or older) in a small town, and the selection was based on the number of visits to GPs recorded in the annual statistics of the health center. The participation rate in the interviews was over 70%. The nonparticipants were younger, and there were more men among them than in the interviewed group. We used the SCL-36 somatization subscale to assess the degree of somatization of the study patients. As a criterion for somatization, we used the cut-off point of eight symptoms out of the 12 listed on the SCL-36 somatization subscale. Previously, various criteria have been used to define somatization. Escobar et al. [16,23] used four symptoms for men and six symptoms for women in DIS to define ``abridged somatization.'' Kroenke et al. [17,53] defined the multisomatoform disorder as three or more medically unexplained physical symptoms and a history of 2 years of somatization. Portegijs et al. [12] used five symptoms on the DSM III symptom list as a cut-off point for somatization among FAs. There are some limitations in our study that must be considered when interpreting the results. The patients were selected from among the health care patients of a small town, where most health care services are obtained from the public health care. This must be borne in mind when generalizing the results to the whole population. We used eight visits per year as a criterion for frequent attendance. The definition of FA patients varies from one author to another. Some authors have given 7 ± 12 visits per year as a criterion for frequent attendance [1±
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3,5,42]. Some others have used a definition based on the most frequently consulting decile of each age group [4,6]. In Finland, Larivaara [5,42] used eight visits as the criterion of FA in his study in a rural health center, and we used the same criterion. This study answers some questions pertaining to somatization and frequent attendance in primary health care. Somatizers constitute a notable group of frequently attending patients, and it is important to note that somatizing FAs use significantly more health care services, both inpatient care in health centers and general hospital inpatient and outpatient care, than nonsomatizing FAs. Patients' hypochondriacal worry combined with their numerous functional somatic symptoms increases significantly the likelihood of frequent visits to GPs in primary health care. The first implication of the study is the importance of recognizing FAs' somatization in the everyday practice of GPs. Symptom lists can be used to aid recognition [19]. Secondly, the study implicates a need for collaboration with mental health professionals when managing FA somatizers. This recommendation can be backed up by the psychiatric comorbidity of FA somatizers found in our study and the cost-effectiveness of psychiatric consultation among primary health care somatizing patients reported by Smith et al. [55]. Furthermore, our third implication emphasizes the need to focus on somatizing FAs' hypochondriacal beliefs and to approach comprehensively their somatic fixation, integrating the biomedical, psychological and social components of the problem during the interview and treatment of somatizing FAs in primary health care, as recommended earlier by McDaniel et al. [56] and Blackwell and DeMorgan [27]. Finally, we emphasize the role of somatic illness as a confounding factor of somatization, which should be considered when studying the somatization phenomenon in primary health care. Acknowledgments This study was supported by grants from the Emil Aaltonen Foundation and the Northern Ostrobothnia Hospital District. We wish to thank Dr. Pentti Nieminen, PhD, from Medical Informatics Group, University of Oulu, for statistical advice. References [1] McArdle C, Alexander WD, Boyle CM. Frequent attenders at a health centre. Practitioner 1974;213:696 ± 702. [2] Smedby B. Storkonsumenter av laÈkarvaÊrd (High consumers of medical care), Soc Med Tidskr 1974;51:462 ± 8. [3] Browne GB, Humphrey B, Pallister R, Browne JA, Shetzer L. Prevalence and characteristics of frequent attenders in a prepaid Canadian family practice. J Fam Pract 1982;14:63 ± 71. [4] Westhead J. Frequent attenders in general practice: medical, psychological and social characteristics. J R Coll Gen Pract 1985;35:337 ± 40.
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[5] Larivaara P. Terveyskeskuksen suurkaÈyttaÈjaÈt (Frequent attenders at doctors' surgeries in a Finnish health care centre), Acta Univ Oul D 164. Oulu: Oulu University, 1987 (English abstract). [6] Von Korff M, Ormel J, Katon W, Lin EHB. Disability and depression among high utilizers of health care. A longitudinal analysis. Arch Gen Psychiatry 1992;49:91 ± 100. [7] JyvaÈsjaÈrvi S, KeinaÈnen-Kiukaanniemi S, VaÈisaÈnen E, Larivaara P, KivelaÈ S. Frequent attenders in a Finnish health centre: morbidity and reasons for encounter. Scand J Prim Health Care 1998;16:141 ± 8. [8] Katon W, Von Korff M, Lin E, Lipscomb P, Russo J, Wagner E, Polk E. Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355 ± 62. [9] Karlsson H, Lehtinen V, Joukamaa M. Psychiatric morbidity among frequent attender patients in primary care. Gen Hosp Psychiatry 1995;17:19 ± 25. [10] Katon W, Lin E, Von-Korff M, Russo J, Lipscomb P, Bush T. Somatization: a spectrum of severity. Am J Psychiatry 1991;148:34 ± 40. [11] Ford CV. Illness as a lifestyle. The role of somatization in medical practice. Spine 1992;17:338 ± 43. [12] Portegijs PJM, van der Horst FG, Proot IM, Kraan HF, Gunther NCHF, Knottnerus JA. Somatization in frequent attenders of general practice. Soc Psychiatry Psychiatr Epidemiol 1996;31:29 ± 37. [13] Karlsson H, Joukamaa M, Lahti I, Lehtinen V, Kokki-Saarinen T. Frequent attender profiles Ð different clinical subgroups among frequent attender patients in primary care. J Psychosom Res 1997;42: 157 ± 66. [14] Lipowski ZJ. Somatization: the concept and its clinical application. Am J Psychiatry 1988;145:1358 ± 68. [15] American Psychiatric Association.. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. [16] Escobar JI, Golding JM, Hough RL, Karno M, Burnham MA, Wells KB. Somatization in the community: relationship to disability and use of services. Am J Public Health 1987;77:837 ± 40. [17] Kroenke K, Spitzer RL, deGruy FV, Hahn SR, Linzer M, Williams JB, Brody D, Davies M. Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997;54:352 ± 8. [18] Quill TE. Somatization disorder. One of medicine's blind spots. JAMA, J Am Med Assoc 1985;254:3075 ± 9. [19] Noyes R, Holt CS, Kathol RG. Somatization. Diagnosis and management. Arch Fam Med 1995;4:790 ± 5. [20] Bridges KW, Goldberg DP. Somatic presentation of DSM-III psychiatric disorders in primary care. J Psychosom Res 1985;29:563 ± 9. [21] Kirmayer LJ, Robbins JM. Three forms of somatization in primary care. Prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis 1991;179:647 ± 55. [22] Kisely S, Goldberg D, Simon G. A comparison between somatic symptoms with and without clear organic cause: results of an international study. Psychol Med 1997;27:1011 ± 9. [23] Escobar JI, Waitzkin H, Silver RC, Gara M, Holman A. Abridged somatization: a study in primary care. Psychosom Med 1998;60: 466 ± 72. [24] Mechanic D. Health and illness behavior and patient ± practitioner relationships. Soc Sci Med 1992;34:1345 ± 50. [25] Robinson JO, Granfield AJ. The frequent consulter in primary medical care. J Psychosom Res 1986;30:589 ± 600. [26] Barsky AJ, Wyshak G. Hypochondriasis and somatosensory amplification. Br J Psychiatry 1990;57:404 ± 9. [27] Blackwell B, DeMorgan NP. The primary care of patients who have bodily concerns. Arch Fam Med 1996;5:457 ± 63. [28] Nemiah JC, Freyberger H, Sifneos PE. Alexithymia: a view of the psychosomatic process. In: Hill OW, editor. Modern trends in psychosomatic medicine. London: Butterworth, 1976. pp. 430 ± 9. [29] Bach M, Bach D. Alexithymia in somatoform disorder and somatic disease: a comparative study. Psychother Psychosom 1996;65:150 ± 2. [30] Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation.
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S. JyvaÈsjaÈrvi et al. / Journal of Psychosomatic Research 50 (2001) 185±192 Alexithymia in medical and psychiatric illness. Cambridge: Cambridge Univ. Press, 1997. Kauhanen J, Julkunen J, Salonen JT. Alexithymia and perceived symptoms: criterion validity of the Toronto Alexithymia Scale. Psychother Psychosom 1991;56:247 ± 52. Katon W, Russo J. Somatic symptoms and depression. J Fam Pract 1989;29:65 ± 9. Simon GE, VonKorff M. Somatization and psychiatric disorder in the NIMH epidemiologic catchment area study. Am J Psychiatry 1991;148: 1494 ± 500. Rogers MP, Weinshenker NJ, Warshaw MG, Goisman RM, Rodriguez-Villa FJ, Fierman EJ, Keller MB. Prevalence of somatoform disorders in a large sample of patients with anxiety disorders. Psychosomatics 1996;37:17 ± 22. Simon GE. Psychiatric disorder and functional somatic symptoms as predictors of health care use. Psychiatr Med 1992;10:49 ± 59. Zoccolillo MS, Cloninger CR. Excess medical care of women with somatization disorder. South Med J 1986;79:532 ± 5. Fink P. The use of hospitalizations by persistent somatizing patients. Psychol Med 1992;22:173 ± 80. Margo KL, Margo GM. The problem of somatization in family practice. Am Fam Physician 1994;49:1873 ± 9. Smith GRJ, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health and health care utilization. Arch Intern Med 1986;146:69 ± 72. Larivaara P, VaÈisaÈnen E, Wynne LC. Developing a family systems approach to rural healthcare: dealing with the ``heavy-user'' problem. Fam, Syst Health 1996;14:291 ± 302. JyvaÈsjaÈrvi S, Joukamaa M, VaÈisaÈnen E, Larivaara P, KivelaÈ S, KeinaÈnen-Kiukaanniemi S. Alexithymia, hypochondriacal beliefs, and psychological distress among frequent attenders in primary health care. Compr Psychiatry 1999;40:292 ± 8. Classification of occupations 1980. Helsinki: Central Statistical Office of Finland, 1981. Derogatis LR, Lipman RS, Covi C. SCL-90: an outpatient psychiatric rating scale Ð preliminary report. Psychopharmacol Bull 1973;9: 13 ± 27.
[44] Fink P, Jensen J, Borgquist L, Brevik JI, Dalgard OS, Sandager I, Engberg M, Hansson L, Holm M, Joukamaa M, et al. Psychiatric morbidity in primary public health care: a Nordic multicentre investigation. Part I: method and prevalence of psychiatric morbidity. Acta Psychiatr Scand 1995;92:409 ± 18. [45] Parker JDA, Bagby RM, Taylor GJ, Endler NS, Schmitz P. Factorial validy of the 20-item Toronto Alexithymia Scale. Eur J Pers 1993;7: 221 ± 32. [46] Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale: I. Item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23 ± 32. [47] Bagby RM, Taylor GJ, Parker JDA. The twenty-item Toronto alexithymia scale: II. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33 ± 40. [48] Pilowsky I. Dimensions of hypochondriasis. Br J Psychiatry 1967;113: 89 ± 93. [49] Speckens AE, Spinhoven P, Sloekers PPA, Bolk JH, Van Hemert AM. A validation study of the Whitely Index, Illness Attitude Scales and Somatosensory Amplification Scale in general medical and general practice patients. J Psychosom Res 1996;40:95 ± 104. [50] Wyshak G, Barsky AJ, Klerman GL. Comparison of psychiatric screening tests in a general medical setting using ROC analysis. Med Care 1991;29:775 ± 85. [51] PaÊlsson N. Functional somatic symptoms and hypochondriasis among general practice patients: a pilot study. Acta Psychiatr Scand 1988;78: 191 ± 7. [52] Franklin LM. The thick-file case. N Z Med J 1971;74:253 ± 5. [53] Kroenke K, Spitzer RL, deGruy FV, Swindle R. A symptom checklist to screen for somatoform disorders in primary care. Psychosomatics 1998;39:263 ± 72. [54] Bach M, Bach D. Predictive value of alexithymia: a prospective study in somatizing patients. Psychother Psychosom 1995;64:43 ± 8. [55] Smith GRJ, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med 1986;314:1407 ± 13. [56] McDaniel SH, Campbell TL, Seaburn DB. Family-oriented primary care. A manual for medical providers. New York: Springer, 1990.
Somatizing frequent attenders in primary health care Simo JyvaÈsjaÈrvia,b,*, Matti Joukamaac,d, Erkki VaÈisaÈnenc,d, Pekka Larivaaraa, Sirkka-Liisa KivelaÈa,e, Sirkka KeinaÈnen-Kiukaanniemia a
Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland b Health Center of Oulainen, Oulainen, Finland c Department of Psychiatry, University of Oulu, Oulu, Finland d Department of Psychiatry, Oulu University Hospital, Oulu, Finland e Unit of General Practice, Oulu University Hospital, Oulu, Finland Received 15 November 1999; accepted 18 May 2000
Abstract Objective: The aim of this case-control study was to investigate the association of somatization with frequent attendance in primary health care. Methods: Frequent attenders in a health center (FAs) (N = 112) and age- and sex-matched controls (COs) (N = 105) constituted the study series. Data were collected from annual statistics, medical records, postal questionnaires and personal interviews. Psychological distress was assessed using Symptom Checklist-36 (SCL-36), alexithymia was measured with Toronto Alexithymia Scale-20 (TAS-20) and hypochondriasis was screened with Whiteley Index (WI). Results: About one-third of FAs were somatizers when a cut-off point of eight symptoms on the SCL-36 somatization subscale was used as a criterion. The significant
association of somatization with frequent attendance disappeared in multivariate analyses when adjusted for age, sex and chronic somatic illnesses. Hypochondriacal beliefs and psychiatric comorbidity were connected with FAs' somatization. Hypochondriacal beliefs explained somatizers' frequent attendance. A significant interaction effect between somatization and hypochondriacal beliefs was found when explaining frequent attendance. Conclusions: The results emphasize the need to use a comprehensive approach of somatization, including hypochondriacal beliefs, when treating somatizing FA patients in primary health care. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Alexithymia; Frequent attenders; Hypochondriasis; Primary health care; Somatization
Introduction Frequent attenders of health care (FAs) represent about 5 ±15% of the population, and they use approximately 20 ± 40% of health care services [1± 7]. According to previous studies, FAs represent a heterogeneous group of patients with a high prevalence of psychiatric disorders [8,9]. Somatization has been connected to the frequent use of health services [10 ± 13]. Lipowski [14] defined somatization as a tendency to experience and communicate somatic distress in response to psychosocial stress and to seek medical help for it. Because of the strict criteria of somatization disorder in DSM IV
* Corresponding author. Health Center of Oulainen, PO Box 13, FIN86301 Oulainen, Finland. Tel.: +358-8-4792563; fax: +358-8-4792529. E-mail address: [email protected] (S. JyvaÈsjaÈrvi).
[15], various other criteria have been developed for somatization, e.g. abridged somatization [16] and multisomatoform disorder [17]. Due to the differences in the criteria used to define somatization and the differences in the study populations, the prevalence of somatization varies from 1% to 12% [14,16,18,19]. Among primary care patients, the prevalence of somatization varies from 8% to 25% [17,19 ±23]. Somatizing patients are often involved in psychosocial difficulties [24], experience substantial distress [19] and show enhanced sensitivity to normal physical sensations [25 ±27]. Somatizing patients tend to use bodily symptoms to communicate, because they have difficulties to express their feelings in words. This emotional illiteracy or ``alexithymia'' [28] associates positively with somatization [29 ± 31]. Somatizing patients are characterized by abnormal illness behavior following the interpretation and attribution of bodily perceptions [14,19,24].
0022-3999/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 2 1 7 - 8
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Most somatizing patients have psychological symptoms, and half of them meet the criteria for a current psychiatric diagnosis, typically somatization disorder, hypochondriasis, depression or anxiety [14,19,20,32± 34]. Somatizing patients prefer general medical services to mental health services [35] and use hospital services excessively [36,37]. Somatization goes frequently unrecognized [18], and physicians tend to focus on excluding organic etiologies through multiple tests and procedures [18,38], which causes the health care system a great deal of expenses [11,14,27,39]. Somatizing patients are challenging for the physician ± patient relationship, and physicians are commonly frustrated by such patients [10,24,27]. There are some studies concerning somatization among FA patients. Katon et al. [10] found somatization to be a continuum: increasing severity of somatic symptoms indicated increasing distress, disability and maladaptive illness behavior. Portegijs et al. [12] found the prevalence of somatization to be 45% in a group of FA patients in general practice. In Finland, previous projects have revealed somatization to be connected with frequent attendance in primary health care. Psychosomatic disease or symptoms were found to be the chief problem of 57% of FA patients [5,40]. About onefifth of FAs were classified as chronically somatizing patients in an urban Finnish health centre [13]. In the first substudy of the present project, we found FAs to prefer somatic reasons for encounter more often than could have been expected on the basis of their psychiatric morbidity [7]. In the second substudy of this project, significant associations of alexithymia, hypochondriasis and psychological distress, including somatization, with frequent attendance were found among men [41]. In this substudy, we hypothesized somatization to be associated with frequent attendance in Finnish primary health care. Secondly, we aimed to clarify how somatizing FAs differ from nonsomatizing FA patients and, finally, to identify the factors connected with somatizers' frequent use of health care services. Method Subjects The study is part of a larger research project dealing with FAs in the rural northern Finnish Health Center of Oulainen [7,41]. Oulainen is a small town with about 8400 inhabitants. The public primary health care facility, including six physicians (GPs) in the health center, is the primary way to access health care services. The patients who had made eight or more visits to GPs during the year 1994 were defined as FAs [5,40]. All the FAs aged 15 years or older during the year 1994 (304 patients) were drawn from the annual statistics of the health center, which cover the inhabitants of Oulainen. For each
FA, one age- and sex-matched control patient (CO) (nonfrequent attender) was drawn from the computerized patient register by random sampling. The control patients had made fewer than eight visits to GPs in 1994. Procedure The study design has been described in detail earlier [7,41]. For every FA and CO patient, the following data were obtained from the annual statistics of the health center: the number of visits to GPs, the number of inpatient episodes in the health center and the number of inpatient days in the health center during the study year 1994. Furthermore, the annual statistics of the Northern Ostrobothnia Hospital District were used to determine the utilization of specialized care: inpatient days in general and mental hospitals, number of inpatient episodes in general and mental hospitals and outpatient visits to general and mental hospitals. The medical records of the FAs and COs were examined by one member of the research team (S.J.), and the following data were collected. The chronic diseases diagnosed by GPs or based on hospital records were classified according to the International Classification of Diseases, 9th revision (ICD-9). The visits to GPs' surgeries during the years 1992 and 1993 were also counted. The total numbers of laboratory visits, laboratory tests, X-ray visits and X-ray films during the year 1994 were counted. Two FA patients and six COs had moved from the municipality, and their medical records were not available. A postal questionnaire was sent to all FAs and COs in 1995. The response rate was 75.6% for FAs and 74.0% for COs. The questionnaire included questions about the patients' sociodemographic backgrounds and living conditions. Socioeconomic status was defined according to Statistics Finland (Central Statistical Office of Finland) [42]. Self-rated health was assessed using a Likert-type scale. Half of the original sample (every second subject selected from the original study population in the date of birth order) were invited to participate in a personal interview. A nurse interviewed 113 FAs and 107 COs in 1996, and the participation rates were 76.4% and 71.3%, respectively. There were no significant differences between the interviewed subjects and the nonparticipants in their medical attendance, marital status, basic education or socioeconomic status. The mean age (S.D.) of the interviewed patients was 52.4 (17.0) years and that of the nonparticipants 42.7 (20.6) years ( P < .001). There were more females in the interviewed group than among the nonparticipants (71.8% vs. 57.1%, P =.014). After the interview, every interviewee filled in a short questionnaire including measures of psychological distress, alexithymia and hypochondriacal beliefs. Feelings of loneliness were elicited with a Likert-type question. To assess psychological distress, a 36-item version (SCL-36) of the Symptom Checklist-90 (SCL-90) was used [43]. SCL-36
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includes subscales for assessing somatization, depression, and anxiety. A mean score equal to or higher than 1.55 per item was considered to indicate psychological distress on the dichotomous variables [44]. We used a cut-off point of eight symptoms or more out of the 12 symptoms on the SCL-36 somatization scale as a criterion for somatization. Altogether 112 of the interviewed FAs and 106 of the interviewed COs filled in the SCL-36. Alexithymia was measured using the Toronto Alexithymia Scale-20 (TAS-20) [45]. TAS-20 is a valid and reliable self-report instrument for assessing alexithymia [46,47]. 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
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of emotion, while Factor 2 reflects difficulties in describing feelings to others, and Factor 3 reflects an externally oriented mode of thinking. The factorial validity of TAS20 has been shown to be relevant [46]. When dichotomizing for alexithymia, sumscores higher than 60 were regarded as alexithymic [30]. Hypochondriasis was screened using the Whiteley Index (WI) originally devised by Pilowsky [48]. The sensitivity and specificity of WI to discriminate between hypochondriacal and nonhypochondriacal patients are good, and WI is reliable in screening for hypochondriasis among primary health care patients [49,50]. Scores equal to or higher than 6 points were regarded as hypochondriacal when dichotomizing for hypochondriasis [51].
Table 1 Sociodemographic characteristics of somatizing and nonsomatizing frequent attenders and controls FAs Variable Age (years) (mean (S.D.)) Sex Female
COs
Somatizers (n = 32)
Nonsomatizers (n = 80)
59.3 (15.6)
50.8 (17.5)
20 (62.5)
62 (77.5)
Marital status Unmarried Cohabiting Married Divorced Widowed
4 1 16 5 6
(12.5) (3.1) (50.0) (15.6) (18.8)
7 (8.8) 3 (3.8) 49 (61.3) 10 (12.5) 11 (13.8)
Basic education Primary school 9 ± 11 years 12 years
27 (84.4) 5 (15.6) 0 (0.0)
42 (52.5) 30 (37.5) 8 (10.0)
Vocational training No training Less than 2 years 2 years or more University degree Other training
21 6 1 0 4
Occupational status Working Unemployed Disability pension Other pension Other
5 (15.6) 2 (6.3) 13 (40.6) 11 (34.4) 1 (3.1)
Socioeconomic classificationc 1 ± 2 Self-employed persons 3 Upper-level nonmanual workers 4 Lower-level nonmanual workers 5 Manual workers 6 ± 9 Students, pensioners, others
5 0 6 18 3
(65.6) (18.8) (3.1) (0.0) (12.5)
(15.6) (0.0) (18.8) (56.3) (9.4)
40 18 14 1 7
(50.0) (22.5) (17.5) (1.3) (8.8)
29 (36.3) 6 (7.5) 11 (13.8) 25 (31.3) 9 (11.3) 6 1 28 42 3
(7.5) (1.3) (35.0) (52.5) (3.8)
Somatizers (n = 17)
Nonsomatizers (n = 89)
P
a
62.6 (15.0)
49.1 (16.1)
.003a
.105b
14 (82.4)
61 (68.5)
.251b
P .020
.845b
.005b
.246b
.013b
.255b
The values are numbers (percentages) unless otherwise indicated. a P values by t tests. b P values by chi-square tests. c Socioeconomic classification according to Statistic Finland: Classification of occupations 1980.
0 1 11 0 5
(0.0) (5.9) (64.7) (0.0) (29.4)
14 (82.4) 1 (5.9) 2 (11.8)
14 7 53 5 10
(15.7) (7.9) (59.6) (5.6) (11.2)
45 (51.1) 31 (35.2) 12 (13.6)
11 1 1 1 2
(64.7) (5.9) (5.9) (5.9) (11.8)
34 29 13 6 7
5 0 3 8 1
(29.4) (0.0) (17.6) (47.1) (5.9)
45 (51.7) 4 (4.6) 11 (12.6) 19 (21.8) 8 (9.2)
1 1 3 11 1
(5.9) (5.9) (17.6) (64.7) (5.9)
9 10 27 41 2
(38.2) (32.6) (14.6) (6.7) (7.9)
(10.1) (11.2) (30.3) (46.1) (2.2)
.131b
.038b
.177b
.186b
.532b
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In the second phase, when explaining the differences between somatizing FAs and nonsomatizing FAs, we used somatization as a dependent variable. Psychiatric diagnosis, alexithymia and hypochondriacal beliefs were considered as potential predictors of FAs' somatization. In further analyses, we tried to find out which factors explain somatizers' frequent attendance. Using frequent attendance as a dependent variable, we included psychiatric illness, alexithymia and hypochondriacal beliefs in the logistic regression model as potential explanatory variables. We also considered the interaction effect between hypochondriacal beliefs and somatization when explaining frequent attendance. In this analysis, we used frequent attendance as a dependent variable and hypochondriacal beliefs and somatization and their interaction term as explanatory factors.
Statistical analyses In the statistical analyses, the SPSS for Windows statistical software package was used. Chi-square tests or Fisher's exact tests were used for between-group comparisons of categorical data and t tests for normally distributed continuous data. Mann ± Whitney U tests were used for nonnormally distributed continuous variables. Multivariate logistic regression analyses were used to calculate the adjusted odds ratio (OR) and its 95% confidence intervals (CI). The selection of explanatory variables to model was conducted by stepwise method. When considering the association between somatization and frequent attendance, we used frequent attendance as a dependent variable and somatization, as hypothesized, as an explanatory variable in logistic regression analyses.
Table 2 Chronic illnesses, self-rated health, loneliness and use of health care services among somatizing and nonsomatizing frequent attenders and controls FAs Variable
COs
Somatizers (n = 32)
Nonsomatizers (n = 80)
P
Somatizers (n = 17)
Nonsomatizers (n = 88)
P
Diagnosed illnesses Number of chronic illnesses Having chronic somatic illness (%) Having a psychiatric diagnosis (%)
2.9 (1.5) 30 (93.8) 10 (31.3)
1.9 (1.4) 68 (85.0) 7 (8.8)
.001 .343a .007a
2.1 (1.6) 15 (88.2) 1 (5.9)
1.1 (1.5) 49 (55.7) 4 (4.5)
.006 .013a 1.000a
Self rated health and loneliness Self rated health good (%) Living alone (%) Feelings of lonelines often (%)
1 (3.4) 9 (31.0) 10 (31.3)
24 (37.5) 9 (13.6) 10 (12.5)
< .001a .046b .019b
2 (14.3) 2 (14.3) 9 (52.9)
45 (61.6) 15 (20.3) 16 (18.0)
.002a 1.000a .004a
7.2 (5.2) 7.1 (5.8)
6.1 (4.1) 5.8 (4.0)
.309 .355
4.0 (4.2) 3.4 (3.1)
2.4 (2.3) 2.2 (2.2)
.124 .146
.874 .692 .792 .374
2.1 8.2 0.8 2.4
1.3 4.7 0.4 1.4
.098 .100 .015 .031
Visits to GP's surgeries Number of visits 1992 Number of visits 1993 Use of laboratory and X-rayc Number of laboratory visits Number of laboratory tests Number of X-ray visits Number of X-ray films
4.9 18.6 1.6 3.0
(4.8) (16.7) (1.8) (4.5)
4.9 15.8 1.5 3.2
(4.7) (11.6) (1.3) (3.7)
(2.4) (9.7) (0.8) (3.4)
(1.9) (7.3) (0.8) (2.4)
Use of health center (HC) ward c care HC ward care episodes Days in HC ward
0.7 (1.2) 4.0 (8.7)
0.2 (0.5) 0.7 (2.4)
.003 .003
0.1 (0.2) 0.1 (0.5)
0.04 (0.3) 0.2 (1.8)
.418 .410
Use of general hospitalized carec Hospitalized care episodes Days in hospital care Outpatient visits
1.4 (1.3) 6.5 (9.4) 9.5 (10.6)
0.8 (1.2) 3.2 (6.8) 6.4 (8.6)
.008 .010 .019
0.4 (0.6) 2.7 (6.5) 3.0 (3.0)
0.3 (0.9) 2.3 (11.6) 1.9 (3.2)
.404 .325 .037
Use of mental health carec Mental hospitalized care episodes Days in mental hospital care Mental outpatient visits
0.03 (0.2) 0.5 (2.7) 2.8 (10.2)
0.0 (0.0) 0.0 (0.0) 1.2 (5.9)
.114 .114 .535
0.0 (0.0) 0.0 (0.0) 0.0 (0.0)
0.01 (0.1) 0.2 (1.8) 0.01 (0.1)
.662 .662 .662
The values are means (S.D.) unless otherwise indicated. P values by Mann ± Whitney U tests. a P values by Fisher's exact test. b P values by chi-square tests. c Use of health care services during 1994.
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Preliminary analyses revealed that chronic somatic illnesses associated significantly with both frequent attendance and somatization and chronic somatic illness as dichotomized variable together with age and sex were considered as confounding variables in the logistic regression analyses. Results The 304 FA patients included 206 (67.8%) women, whose mean age (S.D.) was 51.1 (18.3) years, and 98 (32.2%) men with a mean age of 47.0 (18.7) years; the men were thus significantly younger ( P =.010). The interviewed FAs included 32 (28.6%) somatizing patients, while 17 (16.0%) of the CO patients were somatizers ( P =.027). The mean age (S.D.) of the interviewed FAs was 53.4 (17.3) years and that of COs 51.4 (16.6) years, the difference being insignificant ( P =.393). Somatization was connected with frequent attendance in logistic regression analysis adjusted with age and sex (OR 2.1; 95% CI 1.04± 4.1; P =.039), but when chronic somatic illness was included in the analysis as a confounding variable, the association appeared to be nonsignificant. Differences between somatizing and nonsomatizing FA patients Somatizing FA patients were significantly older and they had significantly lower basic education than nonsomatizing FA patients (Table 1). Occupational status differed significantly between somatizing and nonsomatizing FAs; more somatizing FAs were on disability pension and fewer were working.
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FA somatizers had more chronic illnesses, and they rated their health as poorer than nonsomatizing FAs. About onethird of somatizing FAs lived alone, and the same proportion of them had feelings of loneliness (Table 2). Somatizing FAs used inpatient services of the health center four to five times more than nonsomatizing FAs (Table 2). Use of secondary care was similarly 1.5 ±2-fold among somatizing FAs compared to nonsomatizing FAs. The number of laboratory visits and tests and the use of Xray were quite equal in the two FA groups. FA somatizers were significantly more distressed and alexithymic than nonsomatizing FAs (Table 3). Hypochondriacal beliefs were more common among somatizing FAs than nonsomatizing FAs. In multivariate analyses among FAs, the hypochondriacal beliefs associated significantly with FAs' somatization after adjustment for age, sex and chronic somatic illness (OR 4.3; 95% CI 1.5 ±11.8; P =.005). Similarly, diagnosed psychiatric illness were connected with FAs' somatization (OR 4.3; 95% CI 1.3 ± 14.0; P =.014). Alexithymia did not associate with FAs' somatization in multivariate analysis. Differences between somatizing FA patients and somatizing CO patients There were no significant differences in sociodemographic background between the FA somatizers and CO somatizers (Table 1). The differences in chronic illness, psychiatric morbidity, self-rated health, living alone and feelings of loneliness between the somatizing groups were nonsignificant (Table 2). Psychological distress scores and alexithymia scores were equal between FA and CO somatizers. Somatizing
Table 3 Psychological distress, alexithymia and hypochondriacal beliefs among somatizing and nonsomatizing frequent attenders and controls FAs
COs
Variable
Somatizers (n = 32)
Nonsomatizers (n = 80)
P
Somatizers (n = 17)
Nonsomatizers (n = 89)
P
Psychological distress (SCL-36) Anxiety Depression Total psychological distress
12.2 (2.8) 20.6 (6.4) 65.0 (11.5)
9.2 (2.1) 16.6 (4.2) 46.6 (9.1)
< .001 .001 < .001
11.2 (2.8) 22.0 (4.7) 63.2 (10.0)
9.3 (2.2) 16.3 (3.9) 43.8 (10.3)
< .001 < .001 < .001
Alexithymia Alexithymia (TAS-20 sum) TAS-20 factor 1 TAS-20 factor 2 TAS-20 factor 3
50.8 15.8 12.2 22.7
(10.5) (6.0) (3.7) (4.4)
45.6 (10.6) 12.6 (4.9) 11.3 (4.6) 21.7 (4.9)
.034 .004 .155 .234
51.5 16.2 13.3 22.1
(11.5) (6.5) (5.5) (5.2)
44.2 (10.2) 12.0 (4.4) 11.6 (4.4) 20.7 (5.0)
.008 .009 .185 .253
Hypochondriacal beliefs Hypochondriacal beliefs (WI sum) Having hypochondriacal beliefs (%)
5.8 (2.6) 17 (53.1%)
3.2 (2.6) 16 (20.0%)
< .001 .001a
3.7 (2.3) 2 (11.8%)
2.6 (2.2) 10 (11.2%)
.042 1.000b
Values are means (S.D.) unless otherwise indicated P values by Mann ± Whitney U tests. a P value by chi-square test. b P value by Fisher's exact test.
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FAs had significantly more commonly hypochondriacal beliefs than somatizing CO patients ( P =.006) (Table 3). In multivariate analyses among somatizing patients, hypochondriacal beliefs were significantly associated with somatizers' frequent attendance when controlling for age, sex and chronic somatic illness (OR 8.5; 95% CI 1.5 ± 50.1; P =.018), while psychiatric illness and alexithymia were not significant predictors of somatizers' frequent attendance. When modelling frequent attendance, the interaction effect between somatization and hypochondriacal beliefs was evident. The interaction effect was statistically significant even after adjustment for age, sex and chronic somatic illness and including the main effect term of somatization in the model (OR for interaction term 10.7; 95% CI 2.0 ± 56.9; P =.006). Discussion The main finding of the study was, firstly, that almost one-third of primary care FAs were somatizers, the prevalence of somatization among FAs being significantly higher than among COs. The significant connection between somatization and frequent attendance disappeared when chronic somatic illness was considered as a confounding variable. Secondly, hypochondriacal beliefs and psychiatric illness were connected with FAs' somatization. Thirdly, hypochondriacal beliefs explained somatizing patients' frequent attendance after controlling for age, sex and chronic somatic illness. When explaining frequent attendance in primary health care, a significant interaction effect between somatization and hypochondriacal beliefs was found. The connection of somatization with frequent attendance was confirmed in bivariate analyses, and the finding is in line with some earlier reports [10,12,41]. We found a significant confounding effect of chronic somatic illness on the association of somatization with frequent use of health care services, contrary to the findings of Katon et al. [10]. One-third of FA somatizers had a psychiatric diagnosis according to the medical records, and psychiatric comorbidity associated significantly with FAs' somatization in multivariate analyses. This finding is in line with the findings of Katon et al. [10] and Portegijs et al. [12]. Our study confirmed the previous assumption of the role of hypochondriasis as an explanatory factor of frequent attendance [52]. Hypochondriacal beliefs combined with numerous functional somatic symptoms are strong predictors of frequent attendance in primary health care; this was a new finding. We found almost one-third of the interviewed FAs to be somatizers, while significantly fewer somatizers were found among the CO patients. The prevalence of somatization has varied in previous studies from 20% to 45%, mainly due to differences in the criteria of somatization and the populations [10,12,13].
FA somatizers were older than nonsomatizing FAs and the basic education of somatizing FAs was lower than that of nonsomatizing FAs. These finding were contradictory to those of Katon et al. [10] and Portegijs et al. [12]. The differences in sociodemographic characteristics did not explain somatizers' frequent attendance. Somatizing FAs used general hospital services significantly more than nonsomatizing FAs, but their use of mental health care was not noticeably more frequent, although they had marked psychiatric comorbidity. These results were in agreement with the earlier somatization study findings [35 ± 37]. FA somatizers rated their health as poor and reported feelings of loneliness. Previous studies have shown somatizers' self-rated health [10] and quality of life [17] to be poorer than other patients' self-rated health and quality of life. We found FA somatizing patients to be more distressed than nonsomatizing FA patients, and somatization among FAs also associated with anxiety and depression; these findings are in line with the earlier results on somatizing patients [12,32,33,53]. Alexithymia associated with somatization in bivariate analyses, confirming the results of some earlier studies [29 ± 31,54]; this connection has not been reported earlier among FAs. However, psychological distress and alexithymia did not explain somatizers' frequent attendance. The study group was a sample of primary health care patients (15 years or older) in a small town, and the selection was based on the number of visits to GPs recorded in the annual statistics of the health center. The participation rate in the interviews was over 70%. The nonparticipants were younger, and there were more men among them than in the interviewed group. We used the SCL-36 somatization subscale to assess the degree of somatization of the study patients. As a criterion for somatization, we used the cut-off point of eight symptoms out of the 12 listed on the SCL-36 somatization subscale. Previously, various criteria have been used to define somatization. Escobar et al. [16,23] used four symptoms for men and six symptoms for women in DIS to define ``abridged somatization.'' Kroenke et al. [17,53] defined the multisomatoform disorder as three or more medically unexplained physical symptoms and a history of 2 years of somatization. Portegijs et al. [12] used five symptoms on the DSM III symptom list as a cut-off point for somatization among FAs. There are some limitations in our study that must be considered when interpreting the results. The patients were selected from among the health care patients of a small town, where most health care services are obtained from the public health care. This must be borne in mind when generalizing the results to the whole population. We used eight visits per year as a criterion for frequent attendance. The definition of FA patients varies from one author to another. Some authors have given 7 ± 12 visits per year as a criterion for frequent attendance [1±
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3,5,42]. Some others have used a definition based on the most frequently consulting decile of each age group [4,6]. In Finland, Larivaara [5,42] used eight visits as the criterion of FA in his study in a rural health center, and we used the same criterion. This study answers some questions pertaining to somatization and frequent attendance in primary health care. Somatizers constitute a notable group of frequently attending patients, and it is important to note that somatizing FAs use significantly more health care services, both inpatient care in health centers and general hospital inpatient and outpatient care, than nonsomatizing FAs. Patients' hypochondriacal worry combined with their numerous functional somatic symptoms increases significantly the likelihood of frequent visits to GPs in primary health care. The first implication of the study is the importance of recognizing FAs' somatization in the everyday practice of GPs. Symptom lists can be used to aid recognition [19]. Secondly, the study implicates a need for collaboration with mental health professionals when managing FA somatizers. This recommendation can be backed up by the psychiatric comorbidity of FA somatizers found in our study and the cost-effectiveness of psychiatric consultation among primary health care somatizing patients reported by Smith et al. [55]. Furthermore, our third implication emphasizes the need to focus on somatizing FAs' hypochondriacal beliefs and to approach comprehensively their somatic fixation, integrating the biomedical, psychological and social components of the problem during the interview and treatment of somatizing FAs in primary health care, as recommended earlier by McDaniel et al. [56] and Blackwell and DeMorgan [27]. Finally, we emphasize the role of somatic illness as a confounding factor of somatization, which should be considered when studying the somatization phenomenon in primary health care. Acknowledgments This study was supported by grants from the Emil Aaltonen Foundation and the Northern Ostrobothnia Hospital District. We wish to thank Dr. Pentti Nieminen, PhD, from Medical Informatics Group, University of Oulu, for statistical advice. References [1] McArdle C, Alexander WD, Boyle CM. Frequent attenders at a health centre. Practitioner 1974;213:696 ± 702. [2] Smedby B. Storkonsumenter av laÈkarvaÊrd (High consumers of medical care), Soc Med Tidskr 1974;51:462 ± 8. [3] Browne GB, Humphrey B, Pallister R, Browne JA, Shetzer L. Prevalence and characteristics of frequent attenders in a prepaid Canadian family practice. J Fam Pract 1982;14:63 ± 71. [4] Westhead J. Frequent attenders in general practice: medical, psychological and social characteristics. J R Coll Gen Pract 1985;35:337 ± 40.
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