Psychosomatics 40:396-403, October 1999
© 1999 The Academy of Psychosomatic Medine
Somatic Style and Symptom Reporting in Rheumatoid Arthritis
Arthur J. Barsky, M.D.,
E. John Orav, Ph.D.,
David K. Ahern, Ph.D.,
Malcolm P. Rogers, M.D.,
Shera D. Gruen, B.A., and
Matthew H. Liang, M.D., M.P.H.
Received September 15, 1998; revised February 1, 1999; accepted February 26, 1999. From the Division of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Address correspondence and reprint requests to Dr. Barsky, Division of Psychiatry, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
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ABSTRACT
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The authors studied the relative contributions of psychological characteristics and rheumatoid arthritis (RA) morbidity to RA symptoms and medication side effects. Thirty-one consecutive patients attending an RA clinic completed self-report questionnaires and diaries assessing RA symptoms and somatic style, a constellation of beliefs, attitudes, and concerns about disease and health. After 3 months, the patients were assessed for RA symptoms and self-reported medication side effects. At inception, RA symptoms were associated with several components of somatic style. At 3-month follow-up, changes in RA symptoms and the incidence of medication side effects were predicted by somatic style variables measured at inception. The symptoms of RA and the side effects of RA pharmacotherapy are prospectively predicted by somatic style as well as by the severity and extent of RA.
Key Words: Mood Disorders • Personality Disorder • Rheumatoid Arthritis
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INTRODUCTION
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Patients with the same disease vary widely in the number, severity, and nature of their symptoms. Thus, the correlation between symptoms and the extent of peptic ulceration,1,2 prostatic hypertrophy,3 asthma airway obstruction,4–6 and osteoarthritis7–12 is low. The inconsistent relationship between the extent of disease and the resultant symptoms may be accounted for by such factors as psychiatric distress and life stress. In rheumatoid arthritis (RA), there is a literature on the psychological and social correlates of pain. Psychiatric distress (primarily depression and anxiety) is associated with higher levels of RA pain, even after taking objective measures of disease severity into account.13–17 Most of this research is cross-sectional, making the direction of causality unclear, but longitudinal studies also indicate that baseline depression predicts subsequent pain.18,19 Hypochondriacal attitudes and beliefs about the seriousness of RA are also associated with more severe RA symptoms.20,21 Coping and cognitive style have also been studied as modulators of RA symptoms and pain; passive coping, helplessness, and catastrophizing are cross-sectionally and prospectively associated with greater pain.18,22–29 Also, life stress and the lack of social support are associated with more severe RA pain.30–35 Although several of these studies are prospective in design,36,37 many do not measure RA activity and severity, making it difficult to evaluate the relative contribution of the disease process itself to the patient's somatic symptoms.
We hypothesized that patients with an amplifying somatic style would report more RA symptoms, after taking into account the severity and activity of their RA. We also hypothesized that an amplifying somatic style would be associated with a higher incidence of reported adverse medication side effects due to arthritis medication. Medication side effects, despite their high incidence and crucial importance, have received little systematic investigation as a generic phenomenon. Although there is a widespread clinical impression that certain patients are more likely to complain about side effects than others, the role of personality characteristics in this phenomenon has not been rigorously studied. A secondary aim of the study was to explore the relationship of amplifying somatic style to impairment of daily activities and the frequency of restricted activity days. An amplifying somatic style is defined as the propensity to experience bodily sensations in general (including nonpathological bodily discomfort, normal physiological sensations, and the benign symptoms of mild and self-limited disease) as noxious, alarming, worrisome, and uncomfortable, and to consider them abnormal and pathological—that is, to attribute them to serious disease. Amplification includes a hypervigilance or heightened attentional focus on bodily sensations and a tendency to react to the sensation with affect and cognitions that make them seem more bothersome and noxious.
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METHODS
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Subjects and Setting
The study was conducted in the Rheumatology Center of the Brigham and Women's Hospital, which has more than 20,000 patient visits per year for a wide variety of rheumatological conditions. The study sample consisted of 31 consecutive patients between the ages of 21 and 75 years with a definite diagnosis of RA according to American College of Rheumatology (ACR) criteria, and with a scheduled appointment to see any of the clinic physicians. Patients were excluded if they had severe medical comorbidity that limited life expectancy or caused substantial disability. The study was approved by the hospital's Institutional Review Board.
Design and Procedure
Consecutive outpatients with RA were enrolled, and informed consent was obtained. The patients completed a baseline interview and self-report inventories and rating scales administered by trained research assistants. These assessed somatic style (including hypochondriacal attitudes, somatosensory amplification, and bodily absorption), RA symptoms, and medication side effects. This interview was followed by a 48-hour period of field monitoring, during which patients recorded their symptoms in a diary at four random times during each of 2 consecutive days. The patients were prompted to make these ratings by a preprogrammed alarm wristwatch. Each patient's rheumatologist completed ratings of RA severity and activity and medication side effects. Three months later, the baseline questionnaires were readministered, and the incidence of medication side effects during the intervening period was ascertained.
Variables and Their Measurement
Somatic Style.
Hypochondriacal attitudes (including anxiety about and preoccupation with health and disease) were assessed with the 14-item Whiteley Index. This widely used questionnaire has acceptable reliability and validity.38–42 Responses are scored on a five-point Likert scale. In previous work, the mean score per item on the Whiteley Index was 3.15 in a sample of patients meeting DSM diagnostic criteria for hypochondriasis and 1.56 in a nonhypochondriacal sample of general-medical outpatients.43–45
Bodily amplification was measured with the 10-item Somatosensory Amplification Scale (SSAS), which assesses self-reported sensitivity to normal physiological states and minor bodily discomforts not generally regarded as the symptoms of serious disease (e.g., hunger contractions, insect bites). The SSAS is reliable and valid in ambulatory medical populations and is scored on a five-point Likert scale.43–48 In previous work, the mean SSAS score per item was 2.75 in a sample of hypochondriacal patients and 2.01 in a nonhypochondriacal sample of general-medical outpatients.43–45
Bodily absorption is the capacity for deep involvement in sensory and imaginal events, during which there is a heightened sense of the reality of the attentional object and an imperviousness to distracting stimuli. Absorption has been assessed with the Tellegen Absorption Scale,49,50 which has been revised by Watson to assess somatic and visceral awareness. The resultant 32-item Bodily Absorption Scale has a test–retest reliability of 0.78 over 1 month and 0.65 over 2 months and internal consistency coefficient ( ) of 0.82–0.86 (D. Watson, unpublished data). Factor analysis revealed only a single, general factor and no discrete subscales. A low, though significant, bivariate correlation with neuroticism was found.
Somatization, the tendency to report medically unexplained symptoms, was assessed with the Somatization Disorder section of the Diagnostic Interview Schedule (DIS), Version 3R.51 This highly structured, psychiatric diagnostic interview has been widely used and generates criterion standard diagnoses in conformity with the Diagnostic and Statistical Manual (DSM-IV).52 The Somatization Disorder module asks about the lifetime presence of 39 somatic symptoms and requires that each exceed a severity threshold and be medically unexplained.
Rheumatoid Arthritis Symptoms.
Fourteen specific symptoms of RA (including pain, stiffness, swelling, and restricted joint motion) were assessed with a self-report questionnaire using a five-point, ordinal format. This questionnaire was completed at the baseline interview and 4 times per day for 2 days in a symptom diary.
Medication Side Effects.
Because of the difficulty of definitively ascribing any individual symptom to a particular medication, medication side effects were defined as those symptoms attributed by either patient or physician to a medication. At follow-up, patients were asked about bothersome symptoms in the preceding 90 days that they attributed to their RA medications, whether or not they informed their physicians of them, and whether or not they altered the medication regimen because of them. Conversely, physicians were asked about changes made in the patient's regimen because of side effects.
Functional Impairment.
The ability to perform daily activities was assessed with the Functional Status Questionnaire (FSQ), a self-report instrument used in ambulatory medical populations. We did not use one of the many functional impairment scales developed specifically for RA in order to allow more valid comparisons with other medical populations. The intrascale reliability and construct validity of the FSQ have been demonstrated.53 We used the 31 items that compose four of its six subscales: basic activities of daily living, intermediate activities, social activities, and work performance. The FSQ also assesses the number of restricted activity days (days in which the respondent "cut down" on his/her usual activities for at least half the day) occurring in the past month. The FSQ is scored by computer, which provides numerical ratings from 0 to 100 (maximal function).
Rheumatoid Arthritis Morbidity.
The extent, severity, and activity of RA were assessed by the patients' rheumatologists on the basis of their evaluation of the patient. Disease activity was rated (from 1=not active to 4=very active) on the basis of the physical examination of the affected joints for pain on motion, signs of inflammation, and evidence of synovitis. Disease severity was rated with ACR Classification of Global Status (from 1="least serious" to 4="most serious"). This rating by the rheumatologist is based on an assessment of the extent of physical limitations resulting from RA-induced structural damage.54 Disease extent was measured by rating the presence or absence of extra-articular disease as established by physical and laboratory examination of the patient.
Statistical Methods
Patient characteristics at baseline are summarized for all 31 patients by the mean, standard deviation (SD), and range. Each of the five clinical and functional outcomes were also measured for 27 patients after a 3-month follow-up period and are summarized by the mean, SD, and range of changes between follow-up and baseline for RA symptoms, number of pain sites, and daily activities, and by the mean, SD, and range of events during the 3-month follow-up period for medication side effects and during the 30 days preceding the follow-up for the number of restricted days.
The associations between each of the five outcome variables and each of the four measures of somatic style and the three measures of physician-rated disease severity were summarized and tested by use of a Spearman correlation coefficient (r). To test whether the significant relationships between patient somatic style and outcome persisted after adjustment for disease severity, linear regression models were constructed for each outcome variable with one measure of patient somatic style and one measure of physician-rated disease severity as independent predictors. Results from these models are reported as partial-correlation coefficients and P-values. More complete multiple regression models were not attempted because of the small sample size and collinearity between predictors.
Although our primary hypotheses focus on the relationship between each of the 4 measures of somatic style and the 5 outcome variables in the adjusted regression analyses, the 20 statistical comparisons may lead to false-positive findings due to multiple testing, and caution is therefore urged in interpreting P-values that only marginally meet the usual  0.05 criterion.
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RESULTS
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In all, 51 consecutive, eligible patients were identified. Of these, 31 (60.7%) agreed to participate. There were 23 women (74.2%) and 8 men (25.8%); their mean age was 54.4±15.6 years. Twenty-four patients (77.4%) were married, 3 (9.7%) were divorced, and 4 (12.9%) were single. Twelve patients (38.7%) graduated from high school, 6 (19.4%) had some college education, 7 (22.6%) graduated from college, and 6 (19.4%) had graduate or professional training. Complete follow-up data were obtained on 27 (87.1%) of them after a mean interval of 101.4 days (range: 81–141 days). We have no data on the 20 patients who declined participation, but on superficial inspection they did not appear to differ systematically from those patients who participated.
Table 1 presents the clinical and psychological characteristics of the subjects at inception and at follow-up. Comparable scores on the somatic style measures are available from previous work using a random sample of patients attending a general-medical outpatient clinic.43–45,55 In that comparison population, the mean score on the Whiteley Index was 1.56±0.51, and the mean Somatosensory Amplification Scale score was 2.01±0.55.43–45 The disease activity and severity ratings are typical of ambulatory RA populations, but since RA activity characteristically fluctuates over time, strict norms as such are not available.
We first examined the bivariate correlations between the somatic style variables and the major outcomes (symptoms and disability) at inception (Table 2). Total RA symptoms are significantly associated with hypochondriacal attitudes, somatization, and bodily absorption. Medication side effects are significantly correlated with hypochondriacal attitudes and somatization. Self-reported disability is generally associated with hypochondriacal attitudes and with somatization. Table 3 presents the cross-sectional associations among the physician-rated measures of RA morbidity and pain and disability. The correlations between pain and morbidity are modest, but not statistically significant. The correlations between disability and RA severity are higher than those for disability and RA activity (and approach statistical significance).
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TABLE 2. Relative risk (P) of having a high score on RA outcome (or a low score on daily activities) for an individual scoring high or low on somatic style, by median split
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TABLE 3. Relative risk (P) of having a high score on RA outcome (or a low score on daily activities) for an individual scoring high or low on RA morbidity, by median split
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Linear regression was used to study the cross-sectional associations at inception between somatic style and symptoms and disability, adjusting for RA morbidity (Table 4). These partial correlations indicate that RA symptoms, taking RA morbidity into account, are significantly associated with hypochondriasis and somatization and marginally associated with amplification and bodily absorption. Reported medication side effects are associated with somatization and marginally associated with hypochondriasis. Disability is significantly associated with hypochondriasis and somatization, even after we adjust for RA morbidity. These results did not differ when either ACR class or the presence or absence of extra-articular disease was used as a measure of RA morbidity.
We then examined the follow-up data. Comparison of RA symptoms and disability at inception and follow-up revealed that average scores remained quite stable over time, with the exception of a slight increase in RA severity. Fifty percent of patients were bothered by symptoms they attributed to medication during the 3-month interval, 46.2% reported these to their physicians, and 38.5% reported that their physicians had altered the medication regimen because of these side effects. The same linear regression models were then tested, using the predictor variables measured at inception and the outcome variables measured at follow-up (Table 5). The outcome variables in each regression model were the change in RA symptoms or disability during the follow-up interval or the incidence of medication side effects or number of restricted activity days during the follow-up interval. The predictor variables in each model consisted of one somatic style variable measured at baseline, RA morbidity at baseline, and, when predicting symptoms or disability, the baseline score on that outcome variable. These partial correlations are thus independent of baseline status. The results indicate that hypochondriacal attitudes predict the change in RA symptoms 3 months later, even after taking into account the level of symptoms at inception and the extent of RA morbidity. Hypochondriacal symptoms also predicted the number of restricted activity days during the 30 days preceding follow-up, after we controlled for RA severity, and they were inversely correlated (–0.32) with the change in daily activity functioning. Somatization at inception is a significant, independent predictor of medication side effects, change in daily activity functioning, and restricted activity days. When these analyses were repeated using extra-articular disease and ACR class to measure RA morbidity, these results persisted, except that the correlations between symptoms and hypochondriasis and between daily activities and somatization became nonsignificant.
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TABLE 5. Correlations (and P-values) between somatic style and RA morbidity against outcomes measured at follow-up
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DISCUSSION
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Clinicians have long observed enormous inter-individual variability in symptoms and disability among patients with the same disease status and objective disease severity. The associations observed here suggest that some of this variability may be explained by differences in psychological concerns about health and disease and in the tendency to experience medically unexplained complaints. These associations were seen both cross-sectionally and longitudinally. We emphasize that we assessed symptoms associated specifically with RA (e.g., joint pain and stiffness), rather than medically unexplained complaints, and the findings show that these RA-related symptoms are more severe in those patients who tend to somatize and worry more about their health. It is also important to emphasize that the instruments assessing hypochondriasis, amplification, and bodily absorption do not include somatic symptoms that are specific to RA. Thus, these RA-specific symptoms may be more closely related to the patient's characteristic style of experiencing and reporting symptoms than to the severity and extent of demonstrable disease. All symptoms, of course, whether "functional" or "organic," are composed of both a peripheral, sensory component and a central modulation and processing of that sensation. Future studies of symptom perception and reporting should begin to examine the additive and interactive effects of these two components.
Although far from conclusive, the findings on side effects are notable. They raise the possibility that there is a general propensity or tendency to experience and/or report adverse side effects and therefore that side effects may sometimes be more a characteristic of the patient than the particular medication. Certainly, clinicians have the impression that certain of their patients tend consistently to experience more bothersome medication side effects than do other patients. But although side effects attributed to pharmacological activity are widely reported, there has been little study of nonspecific side effects that are not directly attributable to specific pharmacological properties of medications.
The relationships between somatic style and disability are, on the whole, less robust, but suggest that some of the inter-individual variation in disability and role impairment is attributable to somatic style variables after we take RA morbidity and baseline disability into account.
This pilot study has a number of limitations. First, the relatively small sample size limits internal and external validity and generalizability. Second, the 3-month follow-up interval is too brief to definitively separate antecedent from consequent and to be sure that health concerns lead to worsening of symptoms rather than vice versa. Third, several different clinicians assessed patients' RA morbidity, and the interrater reliability of these determinations was not established. Furthermore, physician ratings of ACR functional class are not pure measures of demonstrable pathology, but are influenced by the patients' symptoms and functional status. (ACR ratings were, however, highly correlated with the physician ratings of disease activity, which is a stricter measure of medical morbidity.) Finally, we did not assess the medication regimen itself, and the relationships between somatic style and side effects could be confounded by differences in the regimen.
Although this is only an exploratory study, it suggests that psychological factors make important contributions to the severity and extent of RA symptoms, and, more specifically, that health concerns and the tendency to somatize result not only in medically unexplained complaints but also in an amplification of medically based symptoms. The results also suggest that some patients may have a characteristic, generalized tendency to report medication side effects, irrespective of the particular drugs they are taking. The findings have several clinical implications. First, they suggest a palliative role for cognitive/behavioral therapies for those patients unduly distressed by RA symptoms. Second, this line of investigation might ultimately enable clinicians to identify, early in the course of their illness, those patients who are most at risk for developing undue pain and disability. Finally, physicians can be more effective if they are aware of the multiple determinants of symptoms, rather than assuming that the demonstrable disease itself is the only significant source of patients' symptoms. Pain that is amplified by disease fears and beliefs is unlikely to respond to anti-rheumatic medications alone. This finding may be especially salient when we consider aggressive pharmacotherapy with more toxic agents.
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ACKNOWLEDGMENTS
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This work was supported by Research Grant MH–40487 from the National Institute of Mental Health, and by grants AR36308 and AI42374 from the National Institute of Arthritis, Musculoskeletal, and Skin Diseases, and an Arthritis Foundation Clinical Science Grant.
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REFERENCES
|
-
Peterson WL, Sturdevant RA, Frankl HD, et al: Healing of duodenal ulcer with an antacid regimen. New Engl J Med 1977; 297:341–345[Abstract]
-
Bodemar G, Walan A: Maintenance treatment of recurrent peptic ulcer by cimetidine. Lancet 1978; 1:403–407[Medline]
-
Frimodt-Moller PC, Jensen KM, Iversen P, et al: Analysis of presenting symptoms in prostatism. J Urol 1984; 132:272–276[Medline]
-
Burdon JGW, Juniper EF, Killian KJ, et al: The perception of breathlessness in asthma. Am Rev Respir Dis 1982; 126:825–828[Medline]
-
Kikuchi Y, Okabe S, Tamura G, et al: Chemosensitivity and perception of dyspnea in patients with a history of near-fatal asthma. New Engl J Med 1994; 330:1329–1334
-
Rubinfeld AR, Pain MCF: Perception of asthma. Lancet 1976; 1:882–884[Medline]
-
Summers MN, Haley WE, Reveille JD, et al: Radiographic assessment and psychologic variables as predictors of pain and functional impairment in osteoarthritis of the knee or hip. Arthritis Rheum 1988; 31:204–209[Medline]
-
Keefe FJ, Caldwell DS, Queen KT, et al: Pain coping strategies in osteoarthritis patients. J Consult Clin Psychol 1987; 55:208–212[Medline]
-
Lunghi M, Miller P, McQuillian W: Psychosocial factors in osteoarthritis of the hip. J Psychosom Res 1978; 22:57–63[Medline]
-
Davis MA, Ettinger WH, Neuhaus JM, et al: Correlates of knee pain among U.S. adults with and without radiographic knee osteoarthritis. J Rheumatol 1992; 19:1943–1949
-
Lichtenberg PA, Skehan MW, Swensen CH: The role of personality, recent life stress and arthritic severity in predicting pain. J Psychosom Res 1984; 28:231–236[Medline]
-
Lichtenberg PA, Swensen CH, Skehan MW: Further investigations of the role of personality lifestyle and arthritic severity in predicting pain. J Psychosom Res 1986; 30:327–337[Medline]
-
Charter RA, Nehemkis AM, Keenan MA, et al: The nature of arthritic pain. Br J Rheumatol 1985; 24:53–60[Abstract/Free Full Text]
-
Moldofsky H, Chester WJ: Pain and mood patterns in patients with rheumatoid arthritis: a prospective study. Psychosom Med 1970; 32:309–318[Abstract/Free Full Text]
-
Young LD: Psychological factors in rheumatoid arthritis. J Consult Clin Psychol 1992; 60:619–627[Medline]
-
Zautra AJ, Burleson MH, Smith CA, et al: Arthritis and the perception of quality of life: an examination of positive and negative affect in rheumatoid arthritis patients. Health Psychol 1995; 14:399–408[Medline]
-
Smith TW, Christensen AJ: Positive and negative affect in rheumatoid arthritis: increased specificity in the assessment of emotional adjustment. Ann Behav Med 1996; 18:75–78
-
Hagglund KJ, Haley WE, Reveille JD, et al: Predicting individual differences in pain and functional impairment among patients with rheumatoid arthritis. Arthritis Rheum 1989; 32:851–858[Medline]
-
Affleck G, Tennen H, Urrows S, et al: Individual differences in the day-to-day experience of chronic pain: a prospective daily study of rheumatoid arthritis patients. Health Psychol 1991; 10:419–426[Medline]
-
Murphy S, Creed F, Jayson MIV: Psychiatric disorder and illness behavior in rheumatoid arthritis. Br J Rheumatol 1988; 27:357–363[Abstract/Free Full Text]
-
Liang MH, Rogers M, Larson M, et al: The psychosocial impact of systemic lupus erythematosis and rheumatoid arthritis. Arthritis Rheum 1984; 27:13–19[Medline]
-
Anderson KO, Keefe FJ, Bradley LA, et al: Prediction of pain behavior and functional status of rheumatoid arthritis patients using medical status and psychological variables. Pain 1988; 33:25–32[Medline]
-
Brown GK, Nicassio PM, Wallston KA: Pain-coping strategies and depression in rheumatoid arthritis. J Consult Clin Psychol 1989; 57:652–657[Medline]
-
Keefe FJ, Brown GK, Wallston KA, et al: Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy. Pain 1989; 37:51–56[Medline]
-
Beckham JC, Keefe FE, Caldwell DS, et al: Pain coping strategies in rheumatoid arthritis: relationships to pain, disability, depression, and daily hassles. Behav Ther 1991; 22:113–124
-
Parker JC, Smarr KL, Buescher KL, et al: Pain control and rational thinking. Arthritis Rheum 1989; 32:984–990[Medline]
-
Buescher KL, Johnston JA, Parker JC, et al: Relationship of self-efficacy to pain behavior. J Rheumatol 1991; 18:968–972[Medline]
-
Affleck G, Tennen H, Pfeiffer C, et al: Appraisals of control and predictability in adapting to a chronic disease. J Pers Soc Psychol 1987; 53:273–279[Medline]
-
Smith TW, Christiansen AJ, Peck JR, et al: Cognitive distortion, helplessness, and depressed mood in rheumatoid arthritis: a four-year longitudinal analysis. Health Psychol 1994; 13:213–217[Medline]
-
DeVellis R, DeVellis B, Sauter S, et al: Predictors of pain and functioning in arthritis. Health Education Research 1986; 1:61–67[Abstract/Free Full Text]
-
Wegener ST: Psychosocial aspects of rheumatic disease: the developing biopsychosocial framework. Curr Opin Rheumatol 1991; 3:300–304[Medline]
-
Goodenow C, Reisine ST, Grady KE: Quality of social support and associated social and psychological functioning in women with rheumatoid arthritis. Health Psychol 1990; 9:266–284[Medline]
-
Affleck G, Tennen H, Urrows S, et al: Person and contextual features of daily stress reactivity: individual differences in relations of undesirable daily events with mood disturbance and chronic pain intensity. J Pers Soc Psychol 1994; 66:329–340[Medline]
-
Anderson KO, Bradley LA, Young LD, et al: Rheumatoid arthritis: review of psychological factors related to etiology, effects, and treatment. Psychol Bull 1985; 98:358–387[Medline]
-
Crosby L: Stress factors, emotional stress, and rheumatoid arthritis disease activity. J Adv Nurs 1988; 13:452–461[Medline]
-
Lorig K, Holman H: Arthritis self-management studies: a twelve-year review. Health Educ Q 1993; 20:17–28[Medline]
-
Callahan LF, Cordray DS, Wells G, et al: Formal education and five-year mortality in rheumatoid arthritis: mediation by helplessness scale scores. Arthritis Care and Research 1996; 9:463–472
-
Pilowsky I: Dimensions of hypochondriasis. Br J Psychiatry 1967; 113:89–93[Abstract/Free Full Text]
-
Pilowsky I: A general classification of abnormal illness behaviours. Br J Med Psychol 1978; 51:131–137[Medline]
-
Pilowsky I, Murrell TGC, Gordon A: The development of a screening method for abnormal illness behavior. J Psychosom Res 1979; 23:203–207[Medline]
-
Barsky AJ, Wyshak G, Klerman GL: Medical and psychiatric determinants of outpatient medical utilization. Med Care 1986; 24:548–560[Medline]
-
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]
-
Barsky AJ, Wyshak G. Hypochondriasis and somatosensory amplification. Br J Psychiatry 1990; 157:404–409[Abstract/Free Full Text]
-
Barsky AJ, Wyshak G, Latham KS, et al: The Somatosensory Amplification Scale and its relationship to hypochondriasis. J Psychiatr Res 1990; 24:323–334[Medline]
-
Barsky AJ, Wyshak G, Klerman GL: Transient hypochondriasis. Arch Gen Psychiatry 1990; 47:746–752[Abstract/Free Full Text]
-
Barsky AJ, Goodson JD, Lane RS, et al: The amplification of somatic symptoms. Psychosom Med 1988; 50:510–519[Abstract/Free Full Text]
-
Barsky AJ, Cleary PD, Sarnie MK, et al: The course of transient hypochondriasis. Am J Psychiatry 1993; 150:484–488[Abstract/Free Full Text]
-
Simon GE, Katon WJ, Sparks PJ: Allergic to life: psychological factors in environmental illness. Am J Psychiatry 1990; 147:901–906[Abstract/Free Full Text]
-
Tellegen A: Practicing the two disciplines for relaxation and enlightenment. J Exp Psychol Gen 1981; 2:217–226
-
Tellegen A, Atkinson G: Openness to absorbing and self-altering experiences ("Absorption"), a trait related to hypnotic susceptibility. J Abnorm Psychol 1971; 83:268–277
-
Robins LN, Helzer JE, Croughan J, et al: National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry 1981; 38:381–389[Abstract/Free Full Text]
-
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
-
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]
-
Hochberg MC, Chang RW, Dwosh I, et al: The American College of Rheumatology 1991 Revised Criteria for the Classification of Global Functional Status in Rheumatoid Arthritis. Arthritis Rheum 1992; 35:498–502[Medline]
-
Barsky AJ, Coeytaux RR, Sarnie MK, et al: Hypochondriacal patients' beliefs about good health. Am J Psychiatry 1993; 150:1085–1089
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ABSTRACT
INTRODUCTION
