Psychosomatics 42:74-77, February 2001
© 2001 The Academy of Psychosomatic Medicine
Emotional, Cognitive, and Behavioral Characteristics of Medical Outpatients
A Preliminary Analysis
Stefania Fabbri, B.Sc.,
Navneet Kapur, M.B., Ch.B.,M.Med.Sc., MRCPsych,
Adrian Wells , B.Sc. (Hons), M.Sc., Ph.D., and
Francis Creed, M.D., FRCP, FRCPsych
Received May 4, 2000; revised July 20, 2000; accepted September 26, 2000. From Department of Psychiatry and Behavioral Sciences, University of Manchester. Address correspondence and reprint requests to Dr. Kapur, Department of Psychiatry and Behavioral Sciences, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL.
ABSTRACT
The authors examined the relationship among emotional, cognitive, and behavioral factors in 65 new outpatients attending neurology and cardiology clinics. The patients completed the Hospital Anxiety and Depression Scale, the Illness Perception Questionnaire, the Somatosensory Amplification Scale, the Private Body Consciousness Scale, and the Health Anxiety Questionnaire. A principal component factor analysis revealed two factors, somatosensory amplification/anxiety and depression/pessimism, that together accounted for 44% of the variance. The factors the authors identified may be useful as a basis for understanding different patterns of illness behavior. The use of these factors may help to rationalize and refine the large number of existing measures and simplify the assessment process, as well as contributing to the development of treatment interventions.
Key Words: Cognitive Factors • Somatic Symptoms • Medical Outpatients
Illness behavior refers to the ways in which symptoms are perceived, evaluated, and acted on by different people.1 It can be conceptualized as having emotional, cognitive, and behavioral components.
Emotional factors have been implicated in the maintenance of illness behavior. For example, in a recent study of rheumatoid arthritis outpatients, Murphy et al.2 found that depression was associated with disability and maladaptive coping strategies. Moreover, emotional consequences of illness, such as anxiety and depressive disorder, are associated with a poorer outcome. Frasure-Smith et al.3 found that depression was a significant predictor of mortality 6 months after a heart attack.
Cognitive behavioral theory and research have emphasized the role of cognitive factors in the etiology and maintenance of maladaptive illness behavior. People develop their own cognitive model of illness, that include beliefs about its etiology, its symptoms, the personal consequences of the illness, and the extent to which the illness is amenable to control or cure.4 This "illness perception" has been shown to be related to health outcome, including rate of improvement in chronic fatigue sufferers and return to work after a heart attack.5
Some researchers have suggested that "somatic sensitivity" is an important determinant of illness behavior, with certain individuals being unusually sensitive to and intolerant of normal bodily sensations.6 These patients may misattribute benign symptoms as a sign of serious disease, make multiple medical visits, and become dissatisfied with their treatment.
"Health anxiety," which may also influence illness behavior, refers to a concern about health in the absence of a pathology or excessive concern when there is some degree of pathology.7 High levels of health anxiety lead to actions aimed at improving health or ruling out the presence of disease, including repeated consultations with medical practitioners.8 Health anxiety may also lead to hypervigilance for bodily events and misinterpretations of normal bodily sensations, thus contributing to somatic sensitivity.6
These concepts have led to the development of a large range of measures that have been validated in different clinical and nonclinical populations. All have distinct psychometric properties. However, there has been less work studying the extent to which these measures overlap. Identifying clusters of related psychological variables may help to refine existing measures and simplify the whole assessment process.
We had the three following objectives in the present study: to determine the emotional, cognitive, and behavioral characteristics of a group of medical outpatients using a variety of measures; to determine the extent to which the various dimensions were interrelated; and to ascertain whether distinct clusters of psychological factors could be identified.
METHODS
The subjects of this study were 65 consecutive new patients attending general neurology or cardiology outpatient appointments at a large U.K. teaching hospital. We selected these populations because previous studies have shown that they include a substantial proportion of patients with medically unexplained symptoms as well as patients with identifiable organic pathology.9
Data were collected by means of a self-report questionnaire administered to the patients immediately after seeing the doctor in the clinic. We recorded demographic details and included the following measures in our study.
The Hospital Anxiety and Depression Scale (HADS) is a 14-item questionnaire, with subscales designed to screen for clinically significant levels of anxiety (HADA) and depression (HADD) in general medical settings.10 It has good internal consistency (Cronbach's alpha=0.80), test-retest reliability (r>0.80), and factorial and concurrent validity.11
The Illness Perception Questionnaire is a theoretically derived measure that assesses the cognitive representations or models of illness that patients adopt in order to make sense of and respond to symptoms.4 We used four of its subscales in the our study. The Identity subscale (IPQID) seeks to identify the number of symptoms patients associate with the disease. The Time Line subscale (IPQT) records beliefs about the perceived duration of the illness. The Consequence subscale (IPQCS) assesses the expected effects and outcomes of the illness. The Cure Control subscale (IPQCT) reflects the degree to which patients believe their illness can be controlled or cured. All subscales have acceptable internal consistency (Cronbach's alpha= 0.73– 0.82), test-retest reliability (r=0.49–0.84), and concurrent and discriminant validity.4
The Somatosensory Amplification Scale (SAS) and Private Body Consciousness Scale (PBCS) are scales that measure the tendency of patients to attend to and amplify normal bodily sensations.6,12 They demonstrate good internal consistency (Cronbach's alpha=0.70) and test-retest reliability (r=0.85).
The Health Anxiety Questionnaire (HAQ) is a self-report instrument designed to identify individuals with high levels of concern about their health. It comprises four subscales that measure health worry and preoccupation (HAQW), fear of illness and death (HAQF), reassurance-seeking behavior (HAQR), and the extent to which bodily symptoms interfere with life (HAQI).8 It has been shown that this questionnaire has good internal consistency (Cronbach's alpha=0.92), test-retest reliability (r=0.87), and discriminant validity.8
RESULTS
The mean±standard deviation (SD) age of the sample was 45.0±15.1 years (range=16–75). Thirty-seven patients (57%) were women, 40 patients (62%) were married or cohabiting, and 30 patients (46%) were in full-time paid employment. Thirty-three patients (51%) had been seen at the neurology clinic, and 32 patients (49%) had been seen at the cardiology clinic. Forty-seven patients (72%) had a confirmed organic diagnosis, and the mean±SD duration, in months, of symptoms was 55±82.17 (range=0–384).
Men had a slightly greater fear of illness and death than women (scores±SD on the Fear subscale of the HAQ; men, 5.9±3.2 vs. women, 3.2±2.6, t=3.4, df=59, P<0.01, independent samples t-test). Men also had more negative perceptions regarding the consequences of their illness (scores on the Consequence subscale of the IPQ; men, 3.2±0.9 vs. women, 2.7±0.7, t=2.2, df=57, P=0.02, independent samples t-test). Cardiology patients were more afraid of illness and death than the neurology patients (scores on the Fear subscale of the HAQ; cardiology, 6.0±3.1 vs. neurology, 2.8±2.6, t=-0.41, df=52, P<0.01, independent samples t-test). There were no other significant differences between groups.
Table 1 shows descriptive statistics for the psychometric variables. Table 2 presents Pearson's correlation coefficients for the variables measured. The variables were significantly interrelated as shown in Table 2.
To explore the structure of the questionnaire responses, we conducted a principal component factor analysis. A scree plot was used to determine the number of factors to extract, and it revealed two principal factors. These factors were rotated to achieve simple structure using the varimax rotation. Table 3 shows the rotated factor matrix. The two factors together accounted for 44% of the variance in the 12 psychological measures, with little overlap between factors. On the basis of factor content, Factor 1 appears to be a dimension of somatosensory amplification-anxiety, while Factor 2 is a dimension of depression-pessimism. The tendency to exaggerate perceptions of symptoms (SAS) loaded on Factor 1 alongside measures of anxiety, health worry, fear, elevated body consciousness, and increased reassurance seeking. Depression loaded on Factor 2, along with beliefs that the illness would have serious consequences, a long duration, and could not be controlled. This factor was also associated with decreased reassurance seeking and an increased perception that the illness was interfering with daily living. The factor structure was similar when cardiology and neurology outpatients were considered separately.
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TABLE 3. Factor matrix showing rotated factor solution for variables measuring the emotional, cognitive, and behavioral characteristics of a group of medical outpatients
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DISCUSSION
These results of our study should be regarded as preliminary because of the comparatively small number of subjects. Our findings may not be generalizable because we restricted ourselves to neurology and cardiology patients, but we have no reason to believe our sample was not reasonably typical of other U.K. outpatient populations. Although we included measures of the number of symptoms (IPQID) and duration of symptoms, we did not have objective measures of disease severity. This was because the main aim of our study was to examine the interrelationships among psychological variables rather than physical variables.
We found significant associations among emotional, cognitive, and behavioral measures in our sample. Further analysis suggested significant clustering of these measures and yielded two major factors: a somatosensory amplification/anxiety factor and a depression-pessimism factor. These factors accounted for 44% of the variance in a variety of psychological measures. Although this is an important finding, it suggests that more than half the variance is accounted for by other factors, perhaps related to disease severity and disability. This is the subject of an ongoing study.
These factors need to be validated in cross-sectional studies with a larger number of subjects, in different populations, and in different settings. Longitudinal studies are required to study the stability of the factors over time and how they relate to issues such as treatment compliance and disease outcome.
Clinically, the factors identified in our study may be useful as a basis for understanding different patterns of illness behavior. Anxious patients appear particularly sensitive to normal bodily sensations. They report hypervigilance for these sensations and have a tendency to amplify them. Consistent with cognitive behavioral formulations, these dimensions are associated with high levels of health anxiety and repeated consultations for reassurance from health professionals. Depressed patients have negative perceptions about their illness; they believe that their illness will last a long time, have serious consequences, and probably cannot be cured or controlled. Patients with depression indicate that their illness causes them considerable disability and are apathetic about seeking reassurance from their doctors.
From the perspective of research in consultation-liaison psychiatry, the use of these factors may help to rationalize and refine the large number of existing measures and simplify the assessment process. By helping us to better understand and measure the components of illness behavior, such factors could ultimately contribute to the development of specific treatment interventions.
ACKNOWLEDGMENTS
The authors thank the clinicians in the neurology and cardiology departments, the patients who took part in the study, and anonymous reviewers for their comments on earlier drafts of this paper.
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