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Psychosomatics 40:470-478, December 1999
© 1999 The Academy of Psychosomatic Medine

Health Attitude Survey

A Scale for Assessing Somatizing Patients

Russell Noyes, Jr., M.D., Douglas R. Langbehn, M.D., Ph.D., Rachel L. Happel, B.S.N., Lori R. Sieren, B.S.N., and Barbara A. Muller, M.D.

Received January 2, 1999; revised March 22, 1999; accepted June 14, 1999. From the Departments of Psychiatry, Preventative Medicine and Environmental Health, and Internal Medicine, University of Iowa College of Medicine; and from the University of Iowa Hospitals and Clinics and Veterans Administration Medical Center, Iowa City, Iowa. Address correspondence and reprint requests to Dr. Noyes, University of Iowa College of Medicine, Psychiatry Research, MEB, Iowa City, IA 52242–1000.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors designed an instrument, the Health Attitude Survey, to assess somatization, and administered it to over 1,000 patients attending a general medicine clinic. Within this population, a series of somatizing patients and control patients were identified for purposes of developing and testing the instrument. The 27-item scale was rapidly administered and acceptable to the patients. Based on comparisons with other measures of somatization, the instrument appeared to be a valid measure of the attitudes and perceptions of somatizing patients, and it distinguished these patients from the control subjects. The measure showed acceptable predictive value and may prove useful in clinical settings, where rapid screening is desired.

Key Words: Health Attitude Survey • Somatization • Diagnostic Tools

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Somatization, the somatic expression of psychological distress, occurs in a sizable proportion of primary care patients.1,2 It is a large problem and source of frustration for both physicians and patients. Given the magnitude and concerns about containing health care costs and at the same time improving patient satisfaction, the problem of somatization appears to have been neglected.3 Among the reasons for this neglect are difficulty in recognizing somatizing patients and the lack of specific treatment for their problems. Poor recognition extends to most psychiatric disorders and is a larger problem that, despite considerable research and discussion, remains largely unsolved.4 Somatization contributes to poor recognition because most psychiatric patients (e.g., those with anxiety and depression) present with somatic symptoms.5–7

Three approaches have been taken to the assessment of somatization in primary care. One involves instruments to identify psychiatric disorders in general. The General Health Questionnaire (GHQ) is an example of self-administered scales designed for this purpose, and more recently, brief structured interviews such as the Primary Care Evaluation of Mental Disorders (PRIME-MD) have been developed.8,9 Both elicit information about somatic symptoms and identify somatoform, as well as other psychiatric, disorders.

Another approach involves identification of unexplained somatic symptoms. The diagnostic criteria of Briquet's syndrome and, subsequently, somatization disorder, included such symptoms that were incorporated into diagnostic interviews and checklists.10–12 Although DSM-III-R called for at least 14 symptoms in women and 12 in men, Escobar et al. showed that a lower threshold of 6 and 4 for women and men, respectively, identified patients who had similar demographic and illness characteristics.13–15 And, several abbreviated checklists have been used to more efficiently screen for these patients.16–18

A third approach began with development of the Whiteley Index. This measure consists of 14 items that Pilowsky found distinguished hypochondriacal from nonhypochondriacal psychiatric patients.19 Subsequently, Pilowsky and Spence added items to measure related illness attitudes and concerns.20 The resulting Illness Behaviour Questionnaire (IBQ) contains 62 binary items distributed among seven factors.21 The instrument has been widely used to examine various aspects of illness behavior and has been shown to have adequate psychometric properties.22,23 However, the IBQ is lengthy and may be influenced by serious disease.24,25

We developed a brief measure for the evaluation of somatization. Items were constructed from the literature on somatization, especially reviews of Lipowski.26–28 Included were items having to do with psychological distress, somatic symptom presentation, and health care utilization. Not included were items on specific somatic symptoms. Several items involved how thoroughly symptoms had been evaluated and explained. This was an effort—unique with this scale—to learn how accurate somatizing patients might be in identifying themselves. Also, a number of items focused on interaction with physicians and satisfaction with medical care, both aspects neglected in prior scales. Our purpose was to develop and test the instrument in a primary care population.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Subjects for this investigation were obtained from the Medicine Clinic of the University of Iowa Hospitals and Clinics. New patients on certain days of the week were asked to complete questionnaires as they arrived for appointments. Patients who screened positively on the Patient Questionnaire of the PRIME-MD or Illness Worry Scale were contacted by telephone for follow-up interviews, using the Clinician Evaluation Guide of the PRIME-MD and the somatoform disorders module of the Structured Clinical Interview for DSM-IV.9,12,29 Patients who presented with somatic symptoms and met criteria for a somatoform, anxiety, or depressive disorder made up the somatizing group.30 Patients from the same clinic who scored negatively on the same questionnaires or who, when interviewed, were found not to have a somatic presentation or a somatoform, anxiety, or depressive disorder made up the control group. Control subjects were randomly selected from consecutively screened patients. Also, patients who screened positively on questionnaires were eligible for assignment to the control group, providing they did not have a somatic presentation and did not meet diagnostic criteria.

Over a 1-year period (1997), about 2,800 new patients were seen in the Medicine Clinic on the days that screening took place. Of these, 1,010 completed the questionnaires and were included in the overall sample. Some of the remaining patients did not receive questionnaires, whereas others appeared not to have time or preferred not to complete them. A few who completed questionnaires were excluded on account of severe physical illness and other reasons (e.g., did not speak English). Of those who were approached after screening, nearly half agreed to be interviewed, whereas the remainder could not be reached or refused further participation. The screened sample of 1,010 patients included 610 women and 400 men who had a mean ± standard deviation (SD) age of 43.0 ± 12.8. In this group of 141 somatizers, there were 110 women and 31 men who had a mean ± SD age of 42.2 ± 13.0. In the group of 34 nonsomatizing control subjects, there were 27 women and 7 men who had a mean ± SD of 45.4 ± 12.9.

Instruments
The patients were screened by using the PRIME-MD developed by Spitzer et al.9 This instrument was designed to identify mental disorders that are common in primary care. Its original version consists of two components: a 1-page Patient Questionnaire and a 12-page Clinician Evaluation Guide or structured interview to follow up on positive responses. The patient questionnaire contains 26 questions about symptoms present during the past month. These questions are divided into diagnostic areas (somatoform, anxiety, depressive, alcohol, and eating disorders) and include the most common physical complaints in primary care. For each diagnostic area, a certain number of positive responses call for administration of the Clinician Evaluation Guide. This interview was used to make DSM-III-R diagnoses.31 The subjects were also evaluated by using the somatoform disorders module of the Structured Clinical Interview for DSM-IV (SCID).12

The patients were also asked to complete the Illness Worry Scale developed by Robbins et al.29 This is a 9-item measure that asks for a yes/no responses. It is a modification of the Whiteley Index that eliminates items influenced by symptoms of physical illness.22 A score of >= 4 was recommended by Kirmayer and Robbins for the identification of hypochondriacal worry.1 The measure is positively correlated with the Whiteley Index and has adequate psychometric properties.29

Initial screening also involved administration of a new instrument, the Health Attitude Survey. This instrument was developed by the authors to assess the phenomenon of somatization, defined by Lipowski as "a tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them."28 In accordance with this descriptive definition, we generated a pool of 36 items covering psychological distress (psychological distress, excessive health worry); somatic symptoms (unexplained symptoms, conflict regarding sick role); and medical care (persistent seeking of care, dissatisfaction with care). Items from existing scales, such as the Illness Behavior Questionnaire, Toronto Alexithymia Scale, Health Perceptions Questionnaire, and Organic Functional Checklist were considered for inclusion.21,32–34 Many items were worded both positively and negatively in an effort to counter response bias. Responses were obtained on five-point bidirectional scales of agreement: 0=strongly disagree, 1=disagree, 2=neutral, 3=agree, and 4=strongly agree. Three items were added to test the acceptability of the measure.

Procedures
As the patients arrived at the Medicine Clinic for their appointments, they were handed screening questionnaires, including the Patient Questionnaire of the PRIME-MD, the Illness Worry Scale, and the Health Attitude Survey. A brief statement on the cover sheet said that the purpose was to learn more about the attitudes patients have about their health and medical care. These questionnaires took less than 10 minutes to complete and, once completed, were handed to the registration clerk or nurse in attendance.

An attempt was made to contact patients who scored above established cutoffs for the Patient Questionnaire or Illness Worry Scale within 7 days of their clinic visit. This contact was made by telephone to complete the clinician evaluation portion of the PRIME-MD and the somatoform disorders module of the SCID. This interview was completed by two nurses who had been trained in the administration of the instruments and achieved satisfactory interrater agreement. Because these interviews required judgment about the extent to which symptoms were explained by physical disease, the nurses frequently sought clarification of this from clinic physicians and medical records, and then reviewed cases with the investigators. The nurses also determined the extent of somatization, according to a procedure proposed by Bridges and Goldberg, and used by Kirmayer and Robbins.1,35

Analyses
We eliminated any Health Attitude Surveys with more than two missing values. Remaining missing values (which occurred in about 5% of the subjects) were replaced with a score of 2 (neutral). As noted earlier, individual items were scored from 0 to 4. Simplified factor scores and total scores for the instrument were obtained by summing scores for individual items. Differences in scores between groups were examined by using analyses of variance.In the case of three-way comparisons among somatizing, severely ill, and control subjects, we used a level of {alpha}=0.05 and Tukey's standardized range test with adjustment for unequal sample sizes.36 Where Pearson correlation coefficients were calculated, the data were further examined for nonlinearity to ensure that the coefficients adequately summarized the two-way interrelationships.

We initially conducted a confirmatory factor analysis to test a priori hypotheses about the underlying structure of the Health Attitude Survey.37 Hypothesized dimensions included psychological distress, excessive health worry, conflict about sick role, dissatisfaction with health care, and persistent utilization of care. Although we found considerable evidence for this structure, the proposed conflict over sick-role factor was not supported. Consequently, we elected to conduct exploratory factor analyses by using oblique rotations and a variety of fitting methods (i.e., principal components, principal factors, and multivariate normal marginal likelihood).38 These analyses all gave comparable results. The number of factors retained was determined by scree plot analysis. After initial analyses, items that correlated only weakly (r<0.40) with all factors or moderately with more than one factor were eliminated. (Compared with the oblique [correlated] factor solutions, orthogonal [uncorrelated] solutions yielded similar structures and nearly identical assocations. We chose oblique solutions because they led to slightly more parsimonious factors that still had only low-to-moderate correlations.) Also eliminated were items that individually failed to discriminate between the somatizing and the control subjects. After this, the factor analysis was repeated.

We calculated simplified factor scores by assigning each item exclusively to the factor with which it correlated highest. The item scores associated with each factor were then summed, and these sums were rescaled so that each would fall within a range from 0 to 1. These simplified scores correlated between 0.93 and 0.99 with conventional (weighted) factor scores (calculated by the various methods mentioned earlier), indicating that the simplified scoring was satisfactory for use in further analyses.

We selected a smaller subset of items for screening in primary care. Our aim was to construct a simple scale by adding the responses to individual items. To accomplish this, we performed a forward-selection procedure for equally weighted predictors developed by one of the authors. This process involves adding the item at each step that minimizes the standardized mean difference in total score between the somatizing patients and control subjects. The method is equivalent to maximizing Student's t statistic for differences between the groups as each item is added. This method has previously performed well for binary predictors and should yield similar results with Likert-scored data.39 This selection was performed by using only the somatizers (N=141) and the control subjects (N=34) identified by structured interview.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The exploratory factor analyses identified six subscales of the Health Attitude Survey that accounted for 61% of the variance. Table 1 shows the factors, together with loadings, for individual items. The factors appeared meaningfully related to six dimensions of somatization that we labeled 1) dissatisfaction with care, 2) frustration with ill health, 3) high utilization of care, 4) excessive health worry, 5) psychological distress, and 6) discordant communication of distress. These factors included 27 of the original 36 items, each having a loading of at least 0.50 (or in one case, 0.48) on the factor with which it was most closely associated. Correlation coefficients among factors ranged from 0.18 to 0.35, with the exception of dissatisfaction with care and frustration with ill health, for which r=0.44.


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TABLE 1. Factor loadings and mean ± standard deviation (SD) scores obtained by somatizing and control subjects on the Health Attitude Survey



Table 1 also compares mean scores on individual items obtained by the somatizers and nonsomatizers. For this comparison, as for all analyses, the scores of positively worded items were reversed. Statistically significant differences or trends were observed for most items. The somatizing patients showed greatest agreement with statements on frustration with ill health. For the statement, "I think this questionnaire deals with important matters," 3.5% of the somatizers and 2.9% of the control subjects expressed disagreement. For "I had no trouble choosing my answers to most questions," the respective figures were 11.3% and 5.9%, and for "I was bothered or upset by the questionnaire," 2.1% and 0% expressed agreement.

Table 2 compares mean factor scores for the men and women within the surveyed population (N=1,010). The women achieved significantly higher scores on frustration with ill health, high utilization of care, and psychological distress.


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TABLE 2. Mean ± SD factor scores obtained on the Health Attitude Survey by men and women attending the medicine clinic



Table 3 shows correlations between factor scores and variables for which information was available on the entire population. As can be seen, no significant correlations with age were observed. As might be expected, a strong negative correlation was observed between overall rating of health (poor, fair, good, very good, or excellent) and the frustration with ill health factor. Modest correlations between this overall rating and the remaining factors were also observed.


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TABLE 3. Correlations between factor scores on the Health Attitude Survey and age, ratings on the patient questionnaire of the PRIME-MD, the Illness Worry Scale, and ratings by clinic physicians



The results were similar for somatic symptoms, as assessed by the Patient Questionnaire of the PRIME-MD. Here, strong positive correlations were observed between the number of symptoms and the remaining factors. Also, psychological symptoms, as measured by the Patient Questionnaire, showed a strong correlation with the psychological distress factor, and modest correlations between psychological symptoms and the other factors were seen. Scores on the Illness Worry Scale showed rather high positive correlations with excessive illness worry and frustration with ill health, but the scores showed moderate-to-high correlations with the remaining factors as well.

Correlations between factor scores and physician ratings are also shown in Table 3. Those between doctor ratings of severity of disease and all the factors were low, the highest being with frustration with ill health (r=0.20). Physician ratings of somatization were modestly correlated with frustration with ill health and dissatisfaction with care, but were relatively low with the remaining factors. Doctors' ratings of psychiatric history were, as might be expected, moderately correlated with psychological distress. Significant but relatively low correlations between physician-assessed psychiatric history and the remaining factors were observed. Physician enthusiasm about care was negatively correlated with most factors at a low-to-moderate level.

Table 4 shows mean Health Attitude Survey factor scores for the somatizing patients, a group of severely ill patients, and nonsomatizing control subjects. The severely ill patients had advanced cancer, heart failure, severe chronic lung disease, etc., and on account of their advanced disease, had been excluded from the somatizing and nonsomatizing groups. Table 4 also shows that the somatizing patients had higher scores on dissatisfaction with care, frustration with ill health, and psychological distress than the severely ill patients, but both groups were comparable in terms of utilization of care.


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TABLE 4. Mean ± SD factor scores for somatizing, severely ill, and control patients



We examined the value of the Health Attitude Survey for distinguishing somatizing and nonsomatizing patients. Table 5 shows mean scores for these groups, together with sensitivity and specificity, when cutoffs were used that roughly balanced these statistics. We also estimated positive and negative predictive values for the primary care setting based on the prevalence estimate of 24% by Kirmayer and Robbins.1 The eight-item subset apparently had superior performance to the 27-item instrument. Note, however, that this estimated performance may have been optimistically biased due to the process of item selection. Estimated sensitivities and specificities for other cutoffs are shown on the ROC (receiver operating characteristic) curves in Figure 1 and Figure 2.


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TABLE 5. Screening performance of items from the Health Attitude Survey





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FIGURE 1. ROC curve for 27-item Health Attitude Survey1




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FIGURE 2. ROC curve for 8-item screening subtest



  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Response to individual items of the Health Attitude Survey distinguished the somatizing and nonsomatizing patients attending a general medicine clinic. The somatizing patients not only perceived themselves as ill, but they also were frustrated with the state of their health. They tended to blame uncaring and ineffective physicians for unexplained health problems. At least some reported distressing worry about and preoccupation with health, and a proportion reported more general psychological distress. In these ways, somatizing patients appear to view themselves very much as others view them and are able to communicate this perception.26–28 This finding indicates that self-report measures may be especially useful in evaluating these patients.

Our results suggest that the Health Attitude Survey is a valid measure of the attitudes and perceptions of somatizing patients. In this study, evidence for external validity came from several sources. For example, scores on various subscales of the 27-item instrument were influenced in predicted directions by demographic and illness variables. Also, the women rated themselves as having more psychological distress and as using more medical care.2 In addition, scores on the Health Attitude Survey correlated moderately with the number of somatic symptoms, as assessed by the Patient Questionnaire of the PRIME-MD, another indicator of somatization.40 Scores on this self-rated instrument were also moderately correlated with ratings of somatization made by clinic physicians. Finally, the somatizing patients scored higher than the nonsomatizing patients, and scores on the measure showed high predictive value in identifying patients with somatization.

Our findings indicate that the Health Attitude Survey is acceptable to patients. With a single exception, fewer than 5% of the somatizing or nonsomatizing patients found the content of the questionnaire unimportant or upsetting or had difficulty in choosing their answers. As might have been expected, the somatizing patients tended to see the content as more important than the control subjects. The issue of acceptability seems important given the subject matter involved. The patients revealed not only anxiety and depressive symptoms but also hypochondriacal concerns, all of which have negative connotations.7 In addition, the somatizing patients expressed the view that, not only were their health problems unexplained, but also they had to deal with ineffective physicians, topics rarely discussed in the health care setting.41

The Health Attitude Survey provides a multidimensional assessment with which to evaluate somatization within clinical populations and screen for somatizing patients. The instrument might be used to characterize various patient groups according to the dimensions comprising the scale. It might also be used to compare the level of somatization between or within groups over time. With respect to screening, our post hoc analysis showed that eight items from the Health Attitude Survey satisfactorily discriminated between the somatizing and nonsomatizing patients. These items represented four of the six dimensions and seemed to capture the core features of somatization. Of course, a small number of items provides a highly efficient method for screening. For instance, before asking patients whether each of a lengthy list of physical symptoms remains unexplained, one might learn nearly as much from replies to a few self-administered questions.

Our data indicate that severe physical illness influenced responses on the Health Attitude Survey. As can be seen in Table 4, such illness produced higher scores on all factors. However, even severely ill patients did not score as high as the somatizing patients we studied. Thus, despite being equivalent in their utilization of care, this severely ill group reported less dissatisfaction with their health and medical care and less psychological distress than the somatizing patients. Also, physician ratings of disease severity were weakly correlated with most factors, again suggesting that the Health Attitude Survey is relatively independent of documented physical disease. Nevertheless, the effect of physical illness is an important concern for instruments designed to identify or measure somatization, including functional somatic symptoms and hypochondriacal worry.42 The Illness Behavior Questionnaire has been challenged on this basis by Zonderman et al.24

The Health Attitude Survey differs from other somatization screening instruments in a number of ways. First of all, it purposely avoids mention of physical symptoms, which might be influenced by physical disease. Instead, the survey asks patients if their health problems lack satisfactory explanation. It also focuses upon dissatisfaction with health and distress related to health problems. And, finally, the survey turns attention to the physician–patient relationship in which dissatisfaction, even antagonism, often exists. The instrument elicits the attitudes and perceptions of somatizing patients themselves and is directed more toward the clinical manifestations of somatization than interpretive mechanisms. In contrast to the Illness Behavior Questionnaire, it contains fewer items of more immediate clinical relevance.21

We tested the Health Attitude Survey in a general medicine clinic at a university hospital. Because this is, in part, a referral center, the results may not generalize to other primary care settings. Also, the value of the instrument or item subsets for evaluating somatizing patients needs to be confirmed by administering it to new samples, and further validation against other indicators of somatization is needed as well. These might include higher rates of childhood abuse, higher levels of interpersonal dysfunction, more frequent iatrogenic substance abuse, and longitudinal data showing more severe somatic symptoms, greater impairment in functioning, and less satisfaction with care in somatizing, compared with the nonsomatizing patients.41,43,44 In addition, the performance of the instrument in relation to other measures of somatization will be important to evaluate. Examination of relationships between factors assessed by the Health Attitude Survey and various dimensions and categories of psychopathology will also be of interest.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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