Psychosomatics
Journal Home Search Current Issue Past Issues Subscribe All APPI Journals Help Contact Us
 
Quicksearch
Advanced Search
Or Search All APPI Journals
This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via HighWire
* Citing Articles via Google Scholar
Google Scholar
* Articles by Hollifield, M.
* Articles by Kellner, R.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Hollifield, M.
* Articles by Kellner, R.
Related Collections
* Primary Care
Psychosomatics 40:380-386, October 1999
© 1999 The Academy of Psychosomatic Medine

Hypochondriasis, Somatization, and Perceived Health and Utilization of Health Care Services

Michael Hollifield, M.D., Susan Paine, M.P.H., Laura Tuttle, M.D., and Robert Kellner, M.D., Ph.D.*

Received August 21, 1998; revised February 1, 1999; accepted February 17, 1999. From the Departments of Psychiatry and Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico. Address correspondence and reprint requests to Dr. Hollifield, Departments of Psychiatry and Family and Community Medicine, University of New Mexico School of Medicine, 2400 Tucker Avenue, Albuquerque, NM 87131. *Dr. Kellner is deceased.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors determined the different effects of hypochondriasis and somatization on health perceptions, health status, and service utilization in a primary care population. The subjects with hypochondriacal responses (HR) on the Illness Attitudes Scales or high somatic concern (HSC) on the Symptom Questionnaire had a worse perception of health and variably used more health services than the control subjects, even though the HR and HSC subjects had the same level of chronic medical disorders. Regression analyses determined that somatization contributed more to negative health perception and service utilization than did hypochondriasis, although an interaction between the two contributed to the use of psychiatric care. The authors discuss the boundary between hypochondriasis and somatization for its implications for research and clinical practice.

Key Words: Hypochondriasis • Primary Care • Health Services • Somatization

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Somatoform disorders are common in primary care medical settings. The most common diagnosis in primary care may be "nonsickness."1 Studies estimate that 10%–80% of patients have somatic complaints for which no adequate physical cause is found.2–7 DSM-III-R Hypochondriasis had a prevalence of 4.2%–6.3% in a general-medical clinic in Boston, Massachusetts8 and 8.5% in the clinics at the University of Iowa (when the duration criteria were excluded).9 Somatization disorder occurs in 3%–5% of primary-care patients.10–12

Primary-care patients with hypochondriasis and somatization are high utilizers of health care. It has been estimated that 10%–20% of the U.S. medical budget is spent on patients who somatize or have hypochondriacal concerns.13 Highly hypochondriacal patients utilize more services than nonhypochondriacal patients,14 and as much as or more than patients with panic disorder.8,9 Patients with somatization disorder have been found to have a threefold higher use of ambulatory services,15 a 50% higher use of office visits,10 and a ninefold higher overall cost than normative patients in the United States.16,17 Patients with hypochondriasis are high utilizers of health care in spite of the evidence that these patients have more symptoms that are less likely to be caused by a medical disorder9 and have no more minor, major, or inactive medical disorders14 than patients without hypochondriasis.

How patients with hypochondriasis and somatization perceive their health is important because this perception is likely related to their distress, disability, and high utilization. It has been found that patients with hypochondriasis rate themselves worse than control subjects on measures of functioning (physical, psychological, work, social, sexual, and overall health),9 and also report more disability than patients with panic disorder8 on the Functional Status Questionnaire.18 Patients with hypochondriasis rate their health problems as having been less thoroughly evaluated, less completely explained, and less adequately treated, and also rate their response to treatment as having been less satisfactory, view their physician as having been less interested or concerned, and report less overall satisfaction with their health care than control subjects9 or patients with panic disorder.8 Somatizers spend 1.3–4.9 days in bed per month, compared with <1 day per month for nonsomatizers.19–21 The disability and cost associated with somatization can be decreased with treatment.22

Comorbidity between hypochondriasis and somatization is high,23 and the relationship between the two is not well understood. Hypochondriasis and somatization have a spectrum of severity, with subclinical cases demonstrating more impairment and health care utilization than control subjects and often as much as diagnosed cases.19,24,25 Thus, the relationship between the two disorders and their subclinical phenomena is important to understand, particularly in the primary-care setting, because this is where these patients most often present.26 If hypochondriasis and somatization have different effects on perceived health and utilization of services, then targeted detection and treatment may be more appropriate than "lumping" them together, as is often done in clinical practice and research.

The current study is a pilot investigation of health status, health perceptions, and health care utilization in willing primary-care patients with hypochondriacal beliefs and high somatic concern, and with neither using previously validated screening instruments. We are thus reporting on subjects with a spectrum of hypochondriasis and somatization, and we will use these terms even though diagnoses were not made. The first hypothesis was that patients with high hypochondriacal responses (HR) and high somatic concern (HSC) perceived their health and health habits to be worse and they had more health care utilization than their control subjects in spite of their having similar levels of chronic medical disorders. The second hypothesis was that the variance in the perception of poor health, poor health habits, and high health care utilization was explained more by high somatic concern than hypochondriacal beliefs. It was expected that these data would suggest that previously validated screening proxies are valid in distinguishing patients with a spectrum of hypochondriasis and somatization from primary-care control subjects. These data were also expected to help clarify the boundary between the phenomena of hypochondriasis and somatization.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects and Setting
A group of 302 willing adult subjects were recruited on random, convenient days from the waiting room at the University of New Mexico Family Practice Center over a 4-month period; 76 subjects refused to participate, and 41 turned in study questionnaires too incomplete for analysis (>10% missing in any psychometric scale), so the final sample size was 185 subjects (response rate=62%). We were able to collect pharmacy data on 73 of the 185 subjects in this study. These data provide information about the number of different medications and medication costs and allow for determination of the chronic disease score.

Instruments
Subjects were recruited by two research assistants and were properly administered informed consent and given instructions in filling out the following self-administered questionnaires:

  1. 1. Demographic information, health status, health perceptions, and health utilization: taken from Part 1 of the "Screening List for Psychosocial Problems (SLP)",26 which are self-report questions. As noted by sample sizes below, data were missing for some subjects in some fields. The 11 variables with the sample size for each regarding health status, health perception, and health utilization are a) smoking (n=185); b) allergies (n=184); c) drug use (n=183); d) alcohol problems (n=150); e) hours worked per week (n=158); f) employment status (n=182); g) disability status (n=182); h) current or past psychiatric treatment (n=184); i) current or past psychotherapy (n=183); j) current or past use of tranquilizers or antidepressants (n=184); and k) current or past hospitalization (the SLP does not specify "medical" or "psychiatric"; n=182). Two variables of utilization, number of prescription medications and medication cost, were not taken from the SLP but from pharmacy data collected for the chronic disease score.
  2. 2. Illness Attitudes Scales (IAS): contains nine scales comprising three items each (each item scored 0–4) that measure domains of attitudes, fears, and beliefs about illness, which were previously constructed from 54 nonpsychotic patients who had either "disease conviction" or who displayed hypochondriacal behaviors.27 These scales have been used for studies in various clinical settings and have been found to be highly reliable on test–retest measures and change in the expected direction with clinical improvement in hypochondriasis. A score of 3 or 4 on any of the six items comprising the Hypochondriacal Beliefs or Disease Phobia scales has been shown, with high sensitivity, to identify patients with the diagnosis of hypochondriasis.28 In this study, these subjects were designated "hypochondriacal responders" (HR), which is used as a proxy for a spectrum of hypochondriasis.
  3. 3. Symptom Questionnaire (SQ): a 92-item true-or-false test with four scales and a total score (SQT). The four scales are Anxiety (SQA), Depression (SQD), Hostility (SQH), and Somatization (SQS). These scales have a high test–retest reliability, have been validated across various clinical samples, and distinguish community employees from both medical and psychiatric patients.29 An SQS score >=14 is "substantial-to-severe" somatization in the absence of physical disease.29 Given the chronic medical disease status in our subjects (described below), an SQS score >=14 in this study defines "high somatic concern" (HSC) as the proxy for a spectrum of somatization.
  4. 4. Chronic Disease Score (CDS): a measure of chronic medical illness derived from the patient's use of prescriptions over a 6-month period.30 A score of 0 indicates no medication use for chronic medical illness. A score of >2 is a significant predictor of both hospitalizations and death over a 1-year period, compared with scores of 0 or 1.30 This score has high stability over a 1-year period and has a high correlation with physician ratings of severity of medical illness. It has also been found to predict hospitalization and mortality in the year following assessment, after controlling for age, gender, and health care visits. Medications used for management of symptoms, such as analgesics and anti-inflammatories, and medications used to treat anxiety and depression are not counted in the CDS.

Statistical Analyses
We performed t-tests and chi-square analyses to determine whether there were group differences between study subjects and refusers for age, education level, and gender mix; t-tests and chi-square analyses were also used to test group differences (HR vs. non-HR and HSC vs. non-HSC) on demographic variables, perceived health status and health habits, utilization patterns, and the CDS. Regression analyses were performed with HR status, HSC status, and the interaction between the two used to determine the unique and interactive contributions of HR and HSC to the dependent variables. Because the dependent variables were of two types (continuous and dichotomous), we performed two types of regressions (linear and logistic).


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The study subjects (N=185) and those who refused to participate (N=76) did not differ in gender mix (female: 76.8% vs. 79%; P=0.71). Study subjects were younger (37.3±12.0 vs. 41.3±11.8 years; t[255]=2.40; P<0.02) and had more years of education (14.4±3.0 vs. 13.2±3.2 years; t[173]=2.43; P<0.02) than refusers. Education status was not determined for 85 of the study subjects (45.9%).

Of the study subjects, 38 (20.5%) were hypochondriacal responders (HR); 61 (33%) had high somatic concern (HSC); and 25 (14% of total sample) were both HR and HSC. These data are presented as descriptors of the sample; they are not meant to suggest prevalence. Sixty percent (n=111) were neither HR nor HSC subjects. Although the constructs of HR and HSC were correlated (r=0.46; P<0.0001), 34.2% (n=13) of HR subjects did not have HSC, and 60.0% (n=36) of HSC subjects were not HR.

Demographics
HR Subjects.
HR subjects and non-HR subjects were similar in gender proportions (female: 76.3% vs. 76.9%, respectively; NS), ethnicity (79.0% white, non-Hispanic vs. 67.4% white, non-Hispanic; NS), average age (37.9±11.5 vs. 37.2±12.2 years; NS), mean years of education (13.9±2.0 vs.14.5±3.2; NS), and marital status (35.1% married vs. 42.5% married; NS).

HSC Subjects.
HSC subjects and non-HSC subjects were similar in gender proportions (female: 80.3% vs. 75.0%, respectively; NS), ethnicity (73.8% white, non-Hispanic vs. 68.3% white, non-Hispanic; NS), average age (38.9±12.0 vs. 36.6±12.0 years; NS), mean years of education (14.2±2.6 vs. 14.5±3.2; NS), and marital status (32.2% married vs. 45.2% married; P<0.10).

Health Status.
The CDS was determined for 73 of the study subjects. The remainder of the sample had pharmacy data too incomplete for appropriate analysis. Sixteen (21.9%) of these were HR, and 28 (38.3%) of these were HSC, which is similar to the percentage of HR and HSC subjects in the total sample. As shown in Table 1, the CDS was not significantly different between HR (n=16) and non-HR (n=57) subjects (1.25 vs. 1.05, respectively; t[71]=0.43; NS), or between HSC (n=28) and non-HSC (n=45) subjects (1.25 vs. 1.00; t[71]=0.65; NS).


View this table:
[in this window]
[in a new window]
 

TABLE 1. Health status, health perceptions, and health habits in hypochondriasis (HR) and somatization (HSC) vs. control subjects (non-HR, and non-HSC)



Health Perception and Health Habits
HR Subjects.
Compared with non-HR control subjects, HR subjects were more likely to be smokers (42.1% vs. 24.5%, respectively; P=0.03) and have allergies (68.4% vs. 33.6%; P<0.01), but not more likely to endorse recreational drug use (5.3% vs. 2.8%; NS) or have alcohol problems (19.4% vs. 11.8%; NS). HR subjects also reported working fewer hours per week (23.6±20.0 vs. 36.0±20.4; P<0.01), being more likely to have been unemployed at some time (86.8% vs. 70.8%; P=0.05), and being disabled (36.8% vs.14.6%; P<0.01) than their non-HR control subjects (Table 1).

HSC Subjects.
Compared with non-HSC control subjects, HSC subjects were more likely to be smokers (39.3% vs. 22.6%; P=0.02) and have allergies (59.0% vs. 31.7%; P<0.01), but not more likely to endorse recreational drug use (3.3% vs. 3.3%; NS) or have alcohol problems (20.4% vs. 9.9%; P=0.08). HSC subjects also reported working fewer hours per week (26.2±20.8 vs. 36.8±20.1; P<0.003) and being disabled (41.0% vs. 8.3%; P<0 01), but did not report more unemployment (78.0% vs. 72.4%; NS) than their HSC control subjects (Table 1).

Health Care Utilization
HR Subjects.
Compared with non-HR control subjects, HR subjects were more likely to report a history of psychiatric treatment (55.3% vs. 24.0%; P<0.01), psychotherapy (65.8% vs. 43.5%; P=0.01), and tranquilizer or antidepressant use at some time (65.8% vs. 26.0%; P<0.01), but did not have a higher prevalence of having ever been hospitalized (89.2% vs. 78.6%; NS). HR subjects did not use a greater number of prescription medications (5.9±4.3 vs. 4.6±3.6; NS) or incur higher medication costs ($283.1±$326.7 vs. $247.7±$354.4; NS) over a 6-month period than their control subjects (Table 2).


View this table:
[in this window]
[in a new window]
 

TABLE 2. Health care utilization in hypochondriasis (HR) and somatization (HSC) vs. control subjects (non-HR and non-HSC)



HSC subjects.
Compared with non-HSC control subjects, HSC subjects were more likely to report a history of psychiatric treatment (47.5% vs. 22.0%; P<0.01), psychotherapy (59.3% vs. 42.7%; P=0.04) and tranquilizer or antidepressant use at some time (65.0% vs. 19.4%; P<0.01); they also had a higher prevalence of ever having been hospitalized (91.7% vs. 75.4%; P<0.01). HSC subjects also used a greater number of prescription medications (6.5±4.8 vs. 3.9±2.5; P=0.01) and incurred higher medication costs ($415.1±$481.3 vs. $156.2±$167.9; P=0.01) over a 6-month period than their control subjects (Table 2).

Regression Modeling
The majority of the dependent variables had dichotomous measures; thus logistic regression was performed and odds ratios (OR) derived. For the dependent variables "hours worked per week," "medication use," and "medication cost," which had continuous measures, linear regression was performed and variance (R2) calculated. In both cases, the main effects of HR and HSC, as well as their interaction term, were entered into each model to determine the best fit for predicting the dependent variable. The interaction term was left in the model only if it had a significant contribution. Table 3 provides the complete results of these analyses.


View this table:
[in this window]
[in a new window]
 

TABLE 3. Regression models of the unique contribution of hypochondriasis (HR), somatization (HSC), and their interaction (HR x HSC) with the dependent variables



A noninteractive model was the best fit for 11 of the 13 dependent variables; only 2 dependent variables benefited from retaining the interaction term. Both hypochondriasis (HR) and somatization (HSC) predicted the use (either past or current) of tranquilizers or antidepressants (HR: {chi}2=7.3, P<0.01, OR=3.2; HSC: {chi}2=23.1, P<0.01, OR=5.9), having allergies (HR: {chi}2=7.9, P<0.01, OR=3.2; HSC: {chi}2=5.7, P<0.05, OR=2.3), and hours worked per week (HR: F=4.79, P=0.03; HSC: F=4.86, P=0.03, R2=0.08). HSC alone predicted ever having been hospitalized ({chi}2=4.9, P<0.05, OR=3.2), being disabled ({chi}2=18.1, P<0.01, OR=6.5), the number of prescription medications (F=6.8, P<0.05, R2=0.11), and medication cost (F=9.9, P<0.01, R2=0.15).

For two dependent variables (Psychiatric Treatment and Psychotherapy), the interaction term of HR and HSC was statistically significant; however, neither main effect was. Subjects with both HR and HSC were more likely to have had past or current psychiatric treatment ({chi}2=6.7, P<0.01, OR=10.8) and psychotherapy ({chi}2=8.2, P<0.01, OR=6.7) than those subjects with only HR, or only HSC, or neither.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The current study used two scales as proxies for hypochondriasis (HR) and somatization (HSC), both of which are highly reliable and sensitive to diagnosis. Hypochondriasis and somatization were almost equally associated with a worse perception of health and functional status, but were not significantly associated with more chronic medical disease as measured by the CDS. Regarding health habits, hypochondriasis and somatization were associated with smoking tobacco, but were not significantly associated with reporting alcohol problems or drug use. Somatization was more strongly associated with health care utilization than was hypochondriasis: somatization was significantly associated with all six of the study's utilization parameters, but hypochondriasis was associated with only three. Regression analyses were performed to determine the unique contribution of hypochondriasis and somatization to the dependent variables. These analyses confirm that somatization was a stronger predictor of negative health perception and especially of higher medical service utilization than was hypochondriasis. However, it was the interaction between hypochondriasis and somatization that predicted the past or current use of tranquilizers, antidepressants, and psychotherapy. Thus, both study hypotheses were generally confirmed, although the authors expected the HR and HSC subjects to endorse more alcohol use, and we expected subjects with HR to have equivalent utilization patterns to subjects with HSC. Furthermore, the Illness Attitudes Scales and the Symptom Questionnaire identified primary-care patients with a spectrum of hypochondriasis and somatization, respectively, and distinguished these groups from patients scoring below the cutoffs (controls) by demonstrating better health perception and less health care utilization in control subjects.

On one hand, these data demonstrating different contributions of hypochondriasis and somatization to perceived health and service utilization were unexpected. Both phenomena have been demonstrated to be associated with more negative perceptions of health and higher health care utilization.8,9,14,15 However, many past research reports consider the diagnoses and phenomena of hypochondriasis and somatization together or do not control one for the presence of the other, for example, in the recent report of Yutzy and colleagues.31 Thus, it is not surprising that different effects have not been reported in past research.

On the other hand, these findings are parsimonious when details from other studies are more carefully reviewed. First, given the high comorbidity between hypochondriasis and somatization,23 research data are often confounded by the presence of both phenomena. This comorbidity has likely limited the field's understanding of the relative contribution of hypochondriasis and somatization to perceptions of health and health care utilization. Second, it has been previously noted that patients with hypochondriasis have poor health habits and are profound "explanation-seekers," rather than treatment-seekers,8,32 seeking the help and concern of others, and then rejecting the assistance as ineffective.33 The current study corroborates this observation, finding similar health perceptions and habits between subjects with hypochondriasis and somatization, but a lower utilization of services by subjects with hypochondriasis. Third, somatic symptoms, but not other hypochondriacal features, have previously been found to be a predictor of higher medical utilization in DSM-III hypochondriasis.14 We presume that both hypochondriasis and somatization disorder were represented in that study, because somatization was not an exclusion. Perhaps it was the somatizing subset of subjects with hypochondriasis that accounted for the higher medical utilization in that study by Barsky and colleagues,14 which is what our current study has also found.

The main strength of this study was in demonstrating differences between the phenomena of hypochondriasis and somatization regarding perceived health and health care utilization in a primary-care setting using proxies for diagnoses. The main limitations are the fact that self-report instruments were used to collect utilization data, except for the CDS and as proxies for diagnosis. There were some data missing for measures of health habits and utilization, although in most cases missing data were minimal. Also, the findings from this sample may not be generalizable to other primary-care settings, to other medical settings, or to other communities. Although this was not a prevalence study, the recruitment method used likely selected a fairly representative clinic sample. A study using probabilistic sampling and strict diagnoses may have quite different results.

Both the IAS and the SQ have been studied extensively and are useful as proxies for diagnosis. Both have high sensitivity, but less is known about their specificity. This may have resulted in false positives in the HR and HSC categories as proxies for hypochondriasis and somatization diagnoses. However, although the nosological status of somatization disorder is becoming established,17,31 less strict diagnostic criteria have been found to be just as useful clinically, and they predict similar levels of impairment and utilization.32 The nosological status of hypochondriasis is less clear,8,33 and the disorder is also considered dimensional.33 Thus, it may be just as clinically relevant, and more practical, to use self-rated proxies rather than diagnoses for research and clinical screening for these somatoform phenomena in primary care.

If the differences between hypochondriasis and somatization reported here are corroborated by further research, it may be important to elucidate how they are different; what these differences have to do with perceived health, impairment, health care utilization, and how to screen effectively for these disorders. In future research it will be important to use more objective measures of health care utilization to compare with the diagnostic proxies used in the current study; these measures may improve nosology, screening, and treatment paradigms directed at the phenomena of hypochondriasis and somatization in primary care.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Brown JW, Robertson LS, Kosa J, et al: A study of general practice in Massachusetts. JAMA 1971; 216:301–306[Abstract/Free Full Text]
  2. Kellner R: Neurosis in general practice. Br J Clin Pract 1965; 19:681–682
  3. Kellner R: Functional somatic symptoms and hypochondriasis: a survey of empirical studies. Arch Gen Psychiatry 1985; 42:821–833[Abstract/Free Full Text]
  4. Kessel WIN: Psychiatric morbidity in a London general practice. British Journal of Preventative and Social Medicine 1960; 14:16–22[Medline]
  5. Mayou R: The nature of bodily symptoms. Br J Psychiatry 1976; 129:55–60[Abstract/Free Full Text]
  6. Mayou R: Chest pain in the cardiac clinic. J Psychosom Res 1978; 17:353–357
  7. Shepherd M, Cooper B, Brown AC, et al: Psychiatric Illness in General Practice. London, UK, Oxford University Press, 1966
  8. Barsky AJ, Barnett MC, Cleary PD: Hypochondriasis and panic disorder: boundary and overlap. Arch Gen Psychiatry 1994; 51:918–925[Abstract/Free Full Text]
  9. Noyes R, Kathol RG, Fisher MM, et al: The validity of DSM–III–R hypochondriasis. Arch Gen Psychiatry 1993; 50:961–970[Abstract/Free Full Text]
  10. DeGruy F, Columbia L, Dickinson P: Somatization disorder in a family practice. J Fam Pract 1987; 25:45–51[Medline]
  11. Kessler LG, Cleary PD, Burke JD Jr: Psychiatric disorders in primary care. Arch Gen Psychiatry 1985; 42:583–590[Abstract/Free Full Text]
  12. Smith GR Jr: Toward more effective recognition and management of somatization disorder. J Fam Pract 1987; 25:551–552[Medline]
  13. Ford CV: The Somatizing Disorders: Illness as a Way of Life. New York, Elsevier, 1983
  14. Barsky AJ, Wyshak G, Klerman GL: Hypochondriasis: an evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiatry 1986; 43:493–500[Abstract/Free Full Text]
  15. Swartz M, Hughes D, George L, et al: Developing a screening index for community studies of somatization disorder. J Psychiatr Res 1986; 20:335–343[Medline]
  16. Smith GR Jr, Monson RA, Ray DC: Psychiatric consultation in somatization disorder: a randomized, controlled study. N Engl J Med 1986; 314:1407–1413
  17. Coryell W: Diagnosis-specific mortality. Arch Gen Psychiatry 1981; 38:939–942[Abstract/Free Full Text]
  18. Jette AM, Davies AR, Cleary PD, et al: The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med 1986; 1:143–149[Medline]
  19. Katon W, Lin E, Von Korff M, et al: Somatization: a spectrum of severity. Am J Psychiatry 1991; 148:34–40[Abstract/Free Full Text]
  20. Rost KM, Smith GR, Kashner TM: Clinical differentiation between somatization disorder patients and somatizers: a test of two hypotheses. Presented at the Fourth Annual NIMH International Conference on the Classification and Treatment of Mental Disorders in General Medical Settings. Washington, DC, June 13, 1990
  21. Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989; 262:914–919[Abstract/Free Full Text]
  22. Smith GR, Rost K, Kashner TM: A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995; 52:238–243[Abstract/Free Full Text]
  23. Kellner R: Psychosomatic Syndromes and Somatic Symptoms. Washington, DC, American Psychiatric Press, 1991, p. 199
  24. Escobar JI, Rubio-Stipec M, Canino G, et al: Somatic symptom index (SSI): a new and abridged somatization construct. J Nerv Ment Dis 1989; 177:140–146[Medline]
  25. Barsky AJ, Cleary PD, Wyshak G, et al: A structured diagnostic interview for hypochondriasis. J Nerv Ment Dis 1992; 180:20–27[Medline]
  26. Kellner R: A problem list for clinical work. Ann Clin Psychiatry 1991; 3:125–136
  27. Kellner R: Abridged Manual of the Illness Attitude Scales (mimeograph). Albuquerque, NM, Department of Psychiatry, University of New Mexico School of Medicine, 1987
  28. Kellner R, Abbott P, Winslow WW, et al: Fears, beliefs, and attitudes in DSM-III hypochondriasis. J Nerv Ment Dis 1987; 175:20–25[Medline]
  29. Kellner R: Manual of the Symptom Questionnaire (mimeograph). Albuquerque, NM, Department of Psychiatry, University of New Mexico School of Medicine, 1987
  30. Von Korff M, Wagner EH, Saunders K: A chronic disease score from automated pharmacy data. J Clin Epidemiol 1992; 45:197–203[Medline]
  31. Yutzy SH, Cloninger CR, Guze SB, et al: DSM-IV field trial: testing a new proposal for somatization disorder, in DSM-IV Sourcebook, Vol. 4. Edited by Widiger TA, Frances AJ, Pincus HA, et al. Washington, DC, American Psychiatric Press, 1998
  32. Starcevic V, Kellner R, Uhlenhuth EH, et al: Panic disorder and hypochondriacal fears and beliefs. J Affect Disord 1992; 24:73–85[Medline]
  33. ABarsky AJ, Klerman GL: Overview: hypochondriasis, bodily complaints, and somatic styles. Am J Psychiatry 1983; 140:273–283[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Psychosom. Med.Home page
A. Martin and F. Jacobi
Features of hypochondriasis and illness worry in the general population in Germany.
Psychosom Med, September 1, 2006; 68(5): 770 - 777.
[Abstract] [Full Text] [PDF]

Home page
 PsychosomaticsHome page
G. Schneider, M. Wachter, G. Driesch, A. Kruse, H.-G. Nehen, and G. Heuft
Subjective Body Complaints as an Indicator of Somatization in Elderly Patients
Psychosomatics, April 1, 2003; 44(2): 91 - 99.
[Abstract] [Full Text] [PDF]

This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via HighWire
* Citing Articles via Google Scholar
Google Scholar
* Articles by Hollifield, M.
* Articles by Kellner, R.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Hollifield, M.
* Articles by Kellner, R.
Related Collections
* Primary Care

Get information about faster international access.

Privacy Policy

Copyright © 1999 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us

American Psychiatric Publishing, Inc. Academy of Psychosomatic Medicine
1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901 * 800-368-5777 * appi at psych.org