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Psychosomatics 42:320-329, August 2001
© 2001 The Academy of Psychosomatic Medicine

Personality Dysfunction Among Somatizing Patients

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

Received July 13, 2000; revised January 4, 2001; accepted January 24, 2001. From the Departments of Biostatistics, Internal Medicine and Psychiatry, University of Iowa Colleges of Medicine and Public Health; and the University of Iowa Hospitals and Clinics and Veterans Administration Medical Center, Iowa City, Iowa. Address reprint requests to Dr. Noyes, Psychiatry Research, Medical Education Bldg, Iowa City, IA 52242. E-mail: russell-noyes{at}uiowa.edu


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
To examine the nature and extent of personality dysfunction related to somatization, the authors administered the Structured Interview for DSM-IV Personality and the NEO Five-Factor Inventory to a series of somatizing and nonsomatizing patients in a general medicine clinic. A greater percentage of somatizers met criteria for one or more DSM-IV personality disorders, especially obsessive-compulsive disorder, than did control patients. Somatizers also differed from control patients with respect to self-defeating, depressive, and negativistic personality traits and scored higher on the dimension of neuroticism and lower on the dimension of agreeableness. In addition, initial and facultative somatizers showed more personality pathology than true somatizers. These findings suggest that certain personality disorders and traits contribute to somatization by way of increased symptom reporting and care-seeking behavior.

Key Words: Personality • Somatization • Primary Care

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The relationship of somatization and somatoform disorders to personality appears to be a close one, although it has received little study. Early descriptions of hysteria, for instance, linked the disorder to histrionic traits, but in the course of developing verifiable criteria, personality features were eliminated from the axis I condition.1 However, observers of the derivative somatization disorder continued to regard personality dysfunction as an important, even essential, feature, and when British psychiatrists were surveyed, over half viewed the disorder as a disturbance of both personality and mental state.2 Also, based on their review, Bass and Murphy3 concluded that most patients with somatoform disorders have personality pathology and that these disturbances are best conceptualized as disorders of personality.

Research based largely on psychiatric populations has demonstrated a link between personality and somatoform disorders, especially somatization disorder. Early interest was focused on histrionic and antisocial personality disorders that were found in substantial proportions of these patients.4–7 On the basis of such findings, investigators proposed that somatization disorder and antisocial personality might be gender-linked expressions of a common hereditary diathesis.8 However, studies leading to this hypothesis looked at the disorders of interest rather than the entire spectrum of personality pathology. Also, treatment-seeking and referral biases may have influenced results. When the full range of disorders was examined, patients with somatization disorder were found to have high rates of personality disorders, but the increase was nonspecific.9–11 For example, Stern et al.10 found an excess of personality disorders among these patients compared to control patients, the most common being passive-dependent, histrionic, and sensitive-aggressive.

Personality dimensions that influence the reporting of symptoms and the pursuit of health care may contribute to somatization and somatoform disorders.12 For example, neuroticism, harm avoidance, and negative affectivity have all been shown to increase the experience of somatic as well as psychological symptoms.13 Likewise, traits that heighten bodily perception or increase self-absorption may also influence symptom reporting.12 Certain other dimensions may contribute to the seeking of health care and to conflictual or unsatisfactory interactions with health care providers. Somatizing patients have been described as angry, resentful, and mistrustful—characteristics that suggest the negative pole of agreeableness.14 Also, research on difficult and frustrating patients has revealed antagonism related to personality disturbances.15,16

The purpose of this study was to examine the distribution of DSM-IV personality disorders and traits in a representative sample of somatizing patients from primary care. We hypothesized that personality disorders would be more prevalent in somatizing than nonsomatizing patients and that the dimensions of neuroticism, extraversion, and agreeableness would distinguish the groups. Among somatizing patients themselves, we hypothesized that more abnormal personality traits would be found among those who acknowledged the contribution of psychological factors to their symptoms than among those who did not. This hypothesis is consistent with the literature comparing psychologizers—those presenting with psychological symptoms—and somatizers.17


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Subjects were recruited from the General Internal Medicine Clinic of the University of Iowa Hospitals and Clinics. New patients on certain days were asked to complete questionnaires as they arrived for appointments, and those who screened positively were contacted by telephone for follow-up interviews. Patients who presented with somatic symptoms and met criteria for a somatoform, anxiety, or depressive disorder made up the somatizing group.18 Those 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, were assigned to the control group. Patients with chronic physical conditions were included in both groups, but those with severe physical or mental illness were excluded. Somatizing patients were those whose presenting symptoms were either unexplained or disproportional to their underlying disease. Control patients were randomly selected from consecutively screened patients.

Over a 1-year period, 2,800 new patients were seen in the General Internal Medicine Clinic on days that screening took place. Of these, 1,010 completed questionnaires. Some of the remaining patients did not receive questionnaires, whereas others appeared not to have time or preferred not to complete them. A few patients who completed questionnaires were excluded on account of severe physical illness (e.g., advanced cancer, cardiac failure) or mental illness (e.g., schizophrenia, dementia) or other reasons (e.g., unable to speak English). Of those who completed questionnaires, about 550 agreed to be interviewed; the remainder could not be reached or declined further participation.

Instruments
Patients were screened using the Primary Care Evaluation of Mental Disorders (PRIME-MD) developed by Spitzer et al.19 This instrument was designed to identify mental disorders that are common in primary care. The PRIME-MD's original version consists of two components: a Patient Questionnaire and a Clinical Evaluation Guide or structured interview to follow up on positive responses. The Patient Questionnaire asks about symptoms during the past month (e.g., somatoform, anxiety, and depressive disorders), including common physical complaints in primary care. For each diagnostic area a certain number of positive responses call for administration of the Clinician Evaluation Guide to make DSM-III-R diagnoses.20 To qualify for a somatoform disorder, for example, a patient had to have three or more somatic symptoms (from a list of 15) that lacked a physical explanation despite a reasonable workup. Subjects were also evaluated using the somatoform disorders module of the Structured Clinical Interview for DSM-IV.21

Patients were also asked to complete the Illness Worry Scale developed by Robbins et al.22 This is a nine-item measure calling for yes or no responses. It is a modification of the Whiteley Index that eliminates items likely to be influenced by physical illness.23 A score of >=4 was recommended by Kirmayer and Robbins24 for the identification of hypochondriacal worry.

The Structured Interview for DSM-IV Personality (SIDP) was administered to somatizing and control patients.25 This is a semistructured interview for the assessment of abnormal personality traits contained in the diagnostic criteria for personality disorders. Information about each trait is elicited by means of standard questions, and subjects are encouraged to elaborate and give examples as well as respond to follow-up questions. Subjects are also encouraged to respond according to what has been true over the past 5 years. Traits are rated on a scale from 0 to 3 (not present to strongly present), and values for traits may be summed to yield scores for individual personality disorders, clusters, and total SIDP. A score of >=2 counts toward a DSM personality diagnosis.

The NEO Five-Factor Inventory (NEO) was used to assess the major dimensions of personality.26 Items in this 60-item version of the NEO Personality Inventory are phrased in the first person and rated on five-point, bidirectional scales (strongly agree to strongly disagree). The responses are summed to yield scores for five basic domains: neuroticism, extraversion, openness, agreeableness, and conscientiousness.

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

Within 7 days, an attempt was made to contact patients who scored above established cutoffs on these screening questionnaires. This was done by telephone to complete the Clinician Evaluation Guide of the PRIME-MD, the somatoform disorders module of the Structured Clinical Interview for DSM-IV, and the Structured Interview for DSM-IV Personality. This interview was completed by one of two nurses who had been trained in the administration of these instruments and who had achieved satisfactory interrater agreement. Because these interviews required judgment about the extent to which symptoms were unexplained, study nurses frequently sought clarification from clinic physicians and medical records. Subsequently, records pertaining to each patient's clinic evaluation were reviewed by one of the investigators (RN), and any patients whose symptoms had been explained were excluded from the somatizing group. The NEO Five-Factor Inventory was mailed to patients who completed the interview.

Study nurses also determined attribution of symptoms according to a procedure developed by Kirmayer and Robbins24 that relies on clinical definitions approximating those proposed by Bridges and Goldberg.27 To accomplish this they asked patients for their presenting symptoms or problems, their spontaneous attributions or explanations of these problems, and their prompted attribution in response to the question, "Do you think nerves or worries could have had anything to do with causing your problem(s)?" Somatizers were those who meet criteria for a psychiatric disorder but who presented with only somatic complaints. Initial somatizers were those who presented with somatic complaints but, when asked about the cause, readily gave psychosocial explanations. Facultative somatizers did not offer psychosocial explanations but readily assented when asked directly whether nerves or worries might have contributed to their symptoms. True somatizers were those who, even on direct questioning, did not accept that nerves or worries might be a cause of their symptoms.

Analyses
We first examined mean differences between somatizing and nonsomatizing patients on the SIDP and NEO. For this we used the Student t-test with Satterthwaite adjustments for unequal variances when necessary.28,29

Next we examined differences in SIDP and NEO mean scores within somatizer subtypes, using analyses of covariance adjusted for age and gender. Tukey-Kramer corrections for multiple comparisons were used at the level of individual tests.29,30

As detailed below, age and gender were significant predicators of SIDP scores. Adjustment was therefore desirable when we compared somatoform disorder subgroups that were unbalanced with respect to these variables. For example, all patients with somatization disorder alone were women. (Among the somatoform disorders this imbalance was of greater concern than possible variance heterogeneity. In contrast, when comparing somatizers to control patients, age and gender were nearly evenly balanced, but substantial variance heterogeneity was frequent. Thus, despite the common goal of comparing mean scores, analyses of covariance [with assumed common variance] were used for one set of analyses and adjusted t-tests for the other.)

We conducted contingency table analyses using the Pearson chi-squared test or Fisher exact test when the expected frequencies were 5 or less in at least 25% of the table cells.31

Factor analyses of relationships between certain SIDP items were conducted using Mplus software to obtain unweighted least-square factor estimates based on underlying tetrachoric or polychoric correlational matrices.32,33 Subjects with missing values on certain outcomes were eliminated from corresponding analyses.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Somatizing patients included 110 women and 31 men with a mean age of 42.2±13.0 years. Nonsomatizing control patients included 27 women and 7 men with a mean age of 45.4±12.9 years. As is shown in Table 1, greater percentages of somatizing patients were unmarried, unemployed, and living alone.


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TABLE 1. Demographic characteristics of somatizing and nonsomatizing patients



Age and gender influenced scores on the personality measures. For instance, somatizing men received higher mean total SIDP scores than did women (45.1±24.9 vs. 28.8±19.9, P<0.0003). Among control patients, men also received higher mean total scores (21.7±15.7 vs. 17.8±18.6, P=0.61), but the difference was not statistically significant. (Despite this apparent difference, there was no significant interaction between gender and somatization status in predicting SIDP scores.) Total SIDP scores were negatively correlated with age among both somatizers and control patients (Pearson r=-0.19, P=0.01, no significant interaction with somatization status).

A greater percentage of somatizing patients met criteria for one or more DSM-IV personality disorders than did nonsomatizing patients (51% vs. 29%, {chi}2=5.15, P=0.02). In terms of personality disorder groupings, greater percentages of somatizing patients met criteria for cluster A disorders (14% vs. 6%, P=0.38), cluster B disorders (17% vs. 12%, {chi}2=0.47, P=0.49), cluster C disorders (40% vs. 18%, {chi}2=6.08, P=0.01), and provisional disorders—self-defeating, depressive and negativistic (also referred to as passive-aggressive) — (22% vs. 6%, {chi}2=4.47, P=0.03) than did nonsomatizing control patients, but only the differences for cluster C and the provisional disorders were significant. With respect to individual disorders, significantly more somatizers qualified for a diagnosis of obsessive-compulsive personality disorder than did control patients (34% vs. 9%, {chi}2=8.30, P=0.004).

Table 2 shows a comparison of mean personality scores obtained on the SIDP by somatizing patients and nonsomatizing control patients. As may be seen, somatizing patients received significantly higher scores for most personality disorders and clusters than did control patients. Also, somatizing patients received a higher mean total SIDP score than did control patients (32.3±22.1 vs. 18.6±17.9, P=0.0009). Among the individual DSM-IV disorders, the largest difference between groups was observed for obsessive-compulsive personality disorder. However, large differences between somatizing patients and control patients were also observed for the three provisional personality disorders: self-defeating, depressive, and negativistic.


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TABLE 2. Scores on the Structured Interview for DSM-IV Personality for somatizing patients and nonsomatizing patients



Somatizing patients differed from nonsomatizing control patients on a number of individual personality traits from the SIDP. Table 3 shows 17 traits for which P values, resulting from t-tests (two-sided) comparing means, were less than P=0.02. These traits included four each from the self-defeating and depressive personalities, three from the negativistic, and two from borderline personality. An exploratory factor analysis showed that a single common factor accounted for much of the relationship among these traits except for numbers 6 and 13. Similar interpretations resulted from analyses of the estimated polychoric correlations as well as principle component and maximum likelihood analyses of raw symptom scores.


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TABLE 3. Individual personality traits from the Structured Interview for DSM-IV Personality on which somatizing patients differed from nonsomatizing patients (t-test, two-way, p<0.02)



Table 4 shows comparisons of somatizing patients and nonsomatizing control patients on the five dimensions measured by the NEO Five-Factor Inventory. Somatizing patients scored significantly higher on neuroticism and lower on agreeableness than did control patients. They also showed a trend toward lower extraversion.


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TABLE 4. Scores on personality dimensions of the NEO Five-Factor Inventory obtained by somatizing patients and nonsomatizing patients



Table 5 shows comparisons of mean personality scores for initial, facultative and true somatizers and control patients on personality clusters assessed by the SIDP and dimensions measured by the NEO. In general, scores for SIDP clusters were highest for initial somatizers, lower for facultative somatizers, and lower still for true somatizers. Although not retested statistically, scores obtained by control patients were lower than those of any of these somatizer subgroups. Mean scores for neuroticism showed a similar gradient, whereas scores for extraversion showed the reverse pattern.


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TABLE 5. Adjusted mean scores for clusters assessed by the Structured Clinical Interview for DSM-IV Personality and dimensions assessed by the NEO Five-Factor Inventory by initial, facultative, and true somatizers



Table 6 shows a comparison of SIDP and NEO scores for patients with DSM-IV somatoform disorders. Somatoform pain disorder, somatization disorder, hypochondriasis, and somatization disorder plus hypochondriasis were the most common somatoform disorders. Comparisons were limited to these categories because other combinations were too infrequent for meaningful analysis. Patients with possible (met DSM-IV criteria except for pseudoneurological symptoms) and definite somatization disorder were included in the comparison. In general, scores were lowest, indicating the least personality pathology, for patients with somatoform pain disorder and highest for those with somatization disorder plus hypochondriasis. The sample size for these comparisons were small and the variability in measures large.


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TABLE 6. Adjusted mean scores on personality measures for patients meeting DSM-IV criteria for major somatoform disorders



When the presence of any current depression (somatizers 59% vs. control patients 9%) was controlled for in the analyses of covariance, differences in SIDP and NEO personality scores were no longer significant.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This is a preliminary study and, as such, has a number of limitations that must be considered in evaluating the results. Some of the limitations have to do with the population of somatizers, others with assessment of personality. To begin with, a proportion of potential subjects could not be contacted or were unwilling to participate; their responses might have differed from those of the patients who took part. Beyond this, it was often difficult to determine when somatic symptoms were unexplained or when worry about illness was excessive. For this reason, a few patients may have been improperly labeled. Diversity within the study population is another reason for caution. The sample included somatizers with multiple unexplained symptoms, with hypochondriacal worry and with somatic presentations of depression and anxiety.24 Such heterogeneity may limit generalizations about the population as a whole. On the other hand, our sample was racially homogeneous and, in view of differences in somatization across racial and cultural groups, results may not generalize to more diverse populations.34

With respect to assessment of personality, our structured interview was administered by telephone and by research assistants who were not blinded to patient status. However, Zimmerman and Coryell 35 showed that reliable data can be obtained using the SIDP administered by telephone. Also, personality assessments were made without interviewing informants. This is an important method for verifying information obtained from subjects that will be important in future studies. In addition, a majority (59%) of our somatizing patients had current depression, which may have influenced assessment of personality functioning. The SIDP uses a 5-year rule in identifying personality patterns that are stable and enduring.25 Behavior during an episodes of major depression is not considered representative of such long-term personality functioning, but traits present during 5 years of chronic depression would count toward a personality diagnosis. Still, mood disturbances may have influenced the assessment of long-standing traits in some patients.

As anticipated, we identified a modest increase in personality pathology in a representative sample of somatizing patients from primary care. Roughly half of the patients who presented with somatic symptoms attributable to psychiatric illness—somatoform, depressive and anxiety disorders—met criteria for one or more DSM-IV personality disorder. This percentage is similar to rates reported for more restricted primary care samples. For example, Katon et al.36 identified abnormal personality traits and disorders in 51% of somatizing and 27% of nonsomatizing patients referred for psychiatric consultation. Similarly, Rost et al.9 found that 61% of somatization disorder patients referred from primary care had DSM-III-R personality disorders, and Leibbrand et al.37 found DSM-IV personality disorders in 53% of somatoform patients referred to a behavioral medicine unit. Our 29% rate of axis II disorders among control patients is comparable to the 20%–34% observed in British primary care populations38,39 but is higher than the 9%–18% in the general population.40–43 There are several possible interpretations of this increase. One is that personality disorders represent a predisposition to somatization and to somatoform disorders.44 Another is that personality disorders render persons vulnerable to depressive and anxiety disorders that have largely somatic presentations in primary care.45 Still another possibility is that the personality disturbances we have identified contribute to treatment-seeking behavior and, for this reason, are overrepresented.

Although the somatizing patients showed more axis II pathology than nonsomatizing control patients, the increase appeared strongest for certain disorders and traits. Among the DSM-IV disorders, obsessive-compulsive personality was significantly more common among the somatizers, and its frequency was more than twice that of any of the remaining disorders. Previous authors have observed obsessive-compulsive personality traits and disorder among patients with somatization disorder6,9,10 and hypochondriasis.12,14,46 The obsessive-compulsive pattern is a likely contributor to somatization. Patients with this disorder are concerned about maintaining control over their physical and mental functioning, and consequently, are threatened by unexplained symptoms. Also, such patients commonly engage in power struggles with physicians, and out of perceived inferiority, challenge their diagnoses and treatments. Such efforts to take control make for difficult doctor-patient relationships.47,48 On the other hand, the obsessive-compulsive personality pattern may contribute to treatment compliance, responsible patienthood, and a more favorable outcome in some instances.49

Among the abnormal personality traits that distinguished somatizers from nonsomatizing control patients, we found a number to have self-defeating, depressive, and negativistic personalities. These traits belong to provisional disorders for which diagnostic criteria have been proposed but not included in DSM-IV. Within this group of individual traits, we found the self-defeating or masochistic personality pattern strongly represented. Depressive and negativistic traits were also prominent, but the former may be difficult to distinguish from chronic depressive disorders in this population. In fact, as indicated, current depression was identified in a substantial proportion of our somatizing patients, and among those with depression, we observed a much higher rate of personality disorders. Of course, depression is likely to increase masochistic tendencies; and guilt, pessimism, and self-deprecation are common to both.47 Even so, the traits of these three personalities—self-defeating, depressive and negativistic—appeared to be intercorrelated and to correspond roughly to a dimension of covert or internally directed aggression identified by Pilkonis (personal communication, December, 1999).50 According to Elliot,51 self-defeating or masochistic traits are often found among somatizing patients, including those with pain and hypochondriasis. Such traits no doubt contribute to care-seeking and to difficult doctor-patient relationships. Patients with this pattern seek relationships in which they feel mistreated and, at the same time, thwart the attempts of others to be helpful. Physicians, whose role it is to help and heal, would seem to provide a ready source of such relationships.

Our findings of more abnormal personality traits as well as more neuroticism and less extraversion in initial compared to true somatizers are as we hypothesized. Our findings are also consistent other research comparing psychologizers and somatizers.17 Psychologizers—patients who present with psychological symptoms—differ from somatizers with respect not only to psychological symptoms but also attitudes and attribution of symptoms. Typically psychologizers have more severe depressive symptoms than do somatizers.52–56 Somatizers, on the other hand, have less positive attitudes toward mental illness, are less introspective, and are more suspicious.57 Somatizers also report more secure interpersonal relationships and score lower on neuroticism.58,59 One interpretation of these findings is that, by presenting somatic rather than psychological symptoms, true somatizers avoid blame.60–62 According to this explanation, true somatizers may have as much personality dysfunction as initial somatizers yet not report it. An alternative explanation is that true somatizers have less psychopathology than initial somatizers and, consistent with that interpretation, have less in the way of personality disturbance. Among true somatizers, physiologic mechanisms, such as autonomic hyperactivity, may make more of a contribution to somatic symptoms. Our findings may have been influenced by inclusion of some patients with multiple unexplained symptoms and hypochondriacal worry among our initial somatizers. Other authors have tended to exclude them from this category.24

The somatizing patients in this investigation were higher on the dimension of neuroticism and lower on the dimension of agreeableness. These findings are similar to those of Hollifield et al.63 who compared hypochondriacal and somatically concerned family practice patients with appropriate control patients. They observed higher neuroticism and lower extraversion in both groups and lower agreeableness and conscientiousness among the somatically concerned (those with multiple somatic symptoms). Neuroticism is a major dimension of personality that reflects the tendency of an individual to experience unpleasant and disturbing emotions. Extensive research has shown that this and the similar, mood-based disposition, negative affectivity, are strongly related to symptom reporting64–66 and are predictive of somatization among the medically ill.13 According to Barsky et al.,67 aversive psychological states may, by increasing arousal and vigilance, lower the threshold for perceiving and reporting symptoms. They may also cause patients to attribute noxious bodily sensation to undiagnosed disease.

Low agreeableness in somatizing patients may be related to help-seeking and to problematic doctor-patient relationships. The negative pole of the agreeableness dimension represents mistrust and antagonism. Individuals with such traits may repeatedly seek relationships with health care providers only to find them conflictual or unsatisfactory. Such a pattern has been described among somatizing patients and has been thought to reflect low agreeableness.12,14 This finding compliments our observation of an increase in obsessive-compulsive, self-defeating, and negativistic traits, all of which are negatively correlated with agreeableness.68 Difficult and frustrating patients have characteristics suggestive of very similar personality disturbances, including vague complaints, excessive demands, chronic complaining, lack of cooperation, lack of treatment response, and high utilization of services.69 Both Lin et al.15 and Hahn et al.16 have found personality disorders overrepresented among such patients. In fact, the difficult primary care patients studied by Hahn et al.16 were distinguished by somatization, personality (axis II), and psychiatric (axis I) disorders. The typical difficult patient, according to these authors, is one with three or four unexplained symptoms, mild to moderate depression, and an abrasive personality.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Lilienfeld SO, Van Valkenburg C, Larntz K, et al: The relationship of histrionic personality disorder to antisocial personality and somatization disorder. Am J Psychiatry 1986; 143:718-722[Abstract/Free Full Text]
  2. Stern J, Murphy M, Bass C: Attitudes of British psychiatrists to the diagnosis of somatization disorder: a questionnaire survey. Br J Psychiatry 1993; 162:463-466[Abstract/Free Full Text]
  3. Bass C, Murphy M: Somatoform and personality disorders: syndromal comorbidity and overlapping developmental pathways. J Psychosom Res 1995; 39:403-427[CrossRef][Medline]
  4. Cloninger CR: The link between hysteria and sociopathy: an integrative model of pathogenesis based on clinical, genetic, and neurophysiological observations, in Psychiatric Diagnosis: Exploration of Biological Predictors. New York, Spectrum, 1978, pp. 189-218
  5. Guze SB: Studies in hysteria. Can J Psychiatry 1983; 28:434-437[Medline]
  6. Kaminsky MJ, Slavney PR: Hysterical and obsessional features in patients with Briquet's syndrome (somatization disorder). Psychol Med 1983; 13:111-120[Medline]
  7. Morrison J: Histrionic personality disorders in women with somatization disorder. Psychosomatics 1989; 30:433-437[Abstract/Free Full Text]
  8. Lilienfeld SO: The association between antisocial personality and somatization disorder: a review and integration of theoretical models. Clin Psychol Rev 1992; 12:641-662[CrossRef]
  9. Rost KM, Akins RN, Brown FN, et al: The comorbidity of DSM-III-R personality disorders in somatization disorders. Gen Hosp Psychiatry 1992; 14:322-326[CrossRef][Medline]
  10. Stern J, Murphy M, Bass C: Personality disorders in patients with somatization disorder: a controlled study. Br J Psychiatry 1993b; 163:785-789
  11. Emerson J, Pankratz L, Joos S, et al: Personality disorders in problematic medical patients. Psychosomatics 1994; 35:469-473[Abstract/Free Full Text]
  12. Kirmayer LJ, Robbins JM, Paris J: Somatoform disorders: personality and the social matrix of somatic distress. J Abnorm Psychol 1994; 103:125-136[CrossRef][Medline]
  13. Russo J, Katon W, Sullivan M, et al: Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics 1994; 35:546-556[Abstract/Free Full Text]
  14. Starcevic V: Relationship between hypochondriasis and obsessive-compulsive personality disorder: close relatives separated by nosological schemes? Am J Psychother 1990; 44:340-347[Medline]
  15. Lin EHB, Katon W, Von Korff M, et al: Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 1991; 6:241-246[Medline]
  16. Hahn SR, Thompson KS, Wills TA, et al: The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 1994; 47:647-657[CrossRef][Medline]
  17. Garcia-Campayo J, Sanz-Carrillo C: A review of the differences between somatizing and psychologizing patients in primary care. Int J Psychiatry Med 1999; 29:337-345[CrossRef][Medline]
  18. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington, DC, 1994
  19. Spitzer RL, Williams JBN, Kroenke K, et al: Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994; 272:1749-1756[Abstract/Free Full Text]
  20. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. American Psychiatric Association, Washington, DC, 1987
  21. First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV, Nonpatient Edition. New York, Biometrics Research Department, New York State Psychiatric Institute, 1995
  22. Robbins JM, Kirmayer LJ, Kapnsta MA: Illness worry and disability in fibromyalgia syndrome. Int J Psychiatry Med 1990; 20:49-63[Medline]
  23. Pilowsky I, Spence ND: Manual for the Illness Behaviour Questionnaire (IBQ). Adelaide, Australia, University of Adelaide, 1983
  24. Kirmayer LJ, Robbins JM: Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics, J Nerv Ment Dis 1991; 179:647-655
  25. Pfohl B, Blum N, Zimmerman M: Structured Interview for DSM-IV Personality. Washington, DC, American Psychiatric Press, 1997
  26. Costa PT, McCrae RR: The NEO Personality Inventory Manual, Odessa, FL, Psychological Assessment Resources, 1985
  27. Bridges RN, Goldberg DP: Somatic presentation of DSM-III psychiatric disorders in primary care. J Psychosom Res 1985; 29:568-579
  28. Satterthwaite FW: An approximate distribution of estimates of variance components. Biometrics Bulletin 1946; 2:110-114[CrossRef]
  29. SAS Institute: SAS/Stat User's Guide, Version 8. Cary, NC, SAS Institute, 1999
  30. Neter J, Kutner MH, Nachtsheim CJ, et al: Applied Linear Statistical Models, Fourth Edition. New York, McGraw-Hill, 1996
  31. Woolson RF: Statistical Methods for the Analysis of Biomedical Data. Wiley, New York, 1987
  32. Muthen BO: A general structural equation model with dichotomous, ordered categorical, and continuous latent variable indicators. Psychometrika 1984; 49:115-132[CrossRef]
  33. Muthen LK, Muthen BO: Mplus, The Comprehensive Modeling Program for Applied Researchers: User's Guide. Los Angeles, Muthen & Muthen, 1998
  34. Kirmayer LJ, Young A: Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med 1998; 60:420-430[Abstract/Free Full Text]
  35. Zimmerman M, Coryell WH: Diagnosing personality disorders in the community: a comparison of self-report and interview measures. Arch Gen Psychiatry 1990; 47:527-531[Abstract/Free Full Text]
  36. Katon WJ, Ries RK, Kleinman A: A prospective DSM-III study of 100 consecutive somatization patients. Compr Psychiatry 1984; 25:305-314[CrossRef][Medline]
  37. Leibbrand R, Hiller W, Fichter: Effect of comorbid anxiety, depressive and personality disorders on treatment outcome of somatoform disorders. Compr Psychiatry 1999; 40:203-209[CrossRef][Medline]
  38. Casey PR, Tyrer PJ, Dillon S: The diagnostic status of patients with conspicuous psychiatric morbidity in primary care. Psychol Med 1984; 14:673-681[Medline]
  39. Casey PR, Tyrer PJ, Platt SP: The relationship between social functioning and psychiatric symptomatology in primary care. Soc Psychiatry 1985; 20:5-9[CrossRef][Medline]
  40. Casey PR, Tyrer PJ: Personality, functioning and symptomatology. J Psychiatr Res 1986; 20:363-374[CrossRef][Medline]
  41. Reich JH, Yates W, Nduagube M: Prevalence of DSM-III personality disorders in the community. Soc Psychiatry Psychiatr Epidemiol 1989; 24:12-16[CrossRef][Medline]
  42. Maier W, Lichterman D, Klingler T, et al: Prevalences of personality disorders (DSM-III-R) in the community. J Personal Disord 1992; 6:187-196
  43. Nestadt G, Samuels JF, Romanoski AJ, et al: DSM-III personality disorders in the population, No NR500. Washington, DC, American Psychiatric Association Annual Meeting, 1993
  44. Paris J: A diathesis-stress model of personality disorders. Psychiatr Ann 1999; 29:692-697
  45. Corruble E, Ginestet D, Guelfi JD: Comorbidity of personality disorders and unipolar major depression: a review. J Affect Disord 1996, 37:157-170
  46. Tyrer P, Fowler-Dixon R, Ferguson B, et al: A plea for the diagnosis of hypochondriacal personality disorder. J Psychosom Res 1990; 34:637-642[CrossRef][Medline]
  47. Walker EA, Katon WJ, Keegan D, et al: Predictors of physician frustration in the care of patients with rheumatological complaints. Gen Hosp Psychiatry 1997; 9:315-323
  48. Salzman L: The Obsessive Personality: Origins, Dynamics and Therapy. New York, Science House, 1968
  49. Tyrer P, Gunderson J, Lyons M, et al: Extent of comorbidity between mental state and personality disorders. J Personal Disord 1997; 11:242-259[Medline]
  50. Pilkonis PA, Kim Y, Proietti JM, et al: Scales for personality disorders developed from the Inventory of Interpersonal Problems. J Personal Disord 1996; 10:355-369
  51. Elliott RL: The masochistic patient in consultation-liaison psychiatry. Gen Hosp Psychiatry 1987; 9:241-250[CrossRef][Medline]
  52. Bridges K, Goldberg D, Evans B, et al: Determinants of somatization in primary care. Psychol Med 1991; 21:473-483[Medline]
  53. Weich S, Lewis G, Donmall R, et al: Somatic presentation of psychiatric morbidity in general practice. Br J Gen Practice 1995; 45:143-147[Medline]
  54. Garcia-Campayo J, Campos R, Marco G, et al: Somatization in primary care in Spain. II: Differences between somatizers and psychologizers in primary care. Br J Psychiatry 1996; 68:348-353
  55. Patel V, Pereira J, Mann H: Somatic and psychological models of common mental disorders in primary care in India. Psychol Med 1998; 28:135-143[CrossRef][Medline]
  56. El-Rufaie OEF, Al-Sabosy MMA, Bener A, et al: Somatized mental disorders among primary care Arab patients: I. Prevalence and clinical and sociodemographic characteristics. J Psychosom Res 1999; 46:549-555[CrossRef][Medline]
  57. Kirmayer LJ, Robbins JM: Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychol Med 1999; 26:937-951
  58. Weich S, Lewis G, Mann A: Effect of early life experiences and personality on the reporting of psychosocial distress in general practice: a preliminary investigation. Br J Psychiatry 1996; 168:116-120[Abstract/Free Full Text]
  59. Wright AF: A study of the presentation of somatic symptoms in general practice by patients with psychiatric disturbance. Br J Gen Practice 1990; 40:459-463[Medline]
  60. Pilowsky I, Murrell TGC, Gordon A: The development of a screening method for abnormal illness behaviour. J Psychosom Res 1979;23:203-207
  61. Goldberg DP, Bridges K: Somatic presentation of psychiatric illness in primary care settings. J Psychosom Res 1988; 32:137-144[CrossRef][Medline]
  62. Craig TKJ, Drake H, Mills K, et al: The South London Somatization Study II. Influence of stressful life events and secondary gain. Br J Psychiatry 1994; 165:248-258[Abstract/Free Full Text]
  63. Hollifield M, Tuttle L, Paine S, et al: Hypochondriasis and somatization related to personality and attitudes toward self. Psychosomatics 1999; 40:387-395[Abstract/Free Full Text]
  64. Costa PT, McCrae RR: Hypochondriasis, neuroticism, and aging: when are somatic complaints unfounded? Am Psychol 1985; 40:19-28[CrossRef][Medline]
  65. Costa PT, McCrae RR: Neuroticism, somatic complaints and disease: is the bark worse than the bite? J Personality 1987; 55:299-316
  66. Pennebaker JW, Watson D: The psychology of somatic symptoms, in Current Concepts of Somatization: Research and Clinical Perspectives, edited by Kirmayer LJ, Robbins JM. Washington, DC, American Psychiatric Press, 1991, pp. 21-35
  67. Barsky AJ, Goodson JD, Lane RS, et al: The amplification of somatic symptoms, Psychosom Med 1988; 50:510-519
  68. Trull TJ: DSM-III-R personality disorders and the five-factor model of personality: an empirical comparison. J Abnorm Psychol 1992; 101:553-560[CrossRef][Medline]
  69. McGaghie WC, Whitenack DC: A scale for measurement of the problem patient labeling process. J Nerv Ment Dis 1982; 170:598-604[Medline]



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