A learning theory model of chronic illness behavior: theory, treatment, and research

Inflammatory Bowel Diseases-related Disability: Risk Factors, Outcomes, and Interventions

The diagnosis of inflammatory bowel disease (IBD) is a life-changing moment for most adults. Biomedical advances over the past 2 decades have resulted in unprecedented growth of therapeutic options for IBD. However, due to the incurable nature of IBD, medical and surgical intervention alone may not be adequate to completely normalize health status and prevent long-term disability. In the biopsychosocial model of health and disease, a person's health and function result from complex physical, psychosocial, and environmental interactions. Adapting the World Health Organization definition, IBD-related disability encompasses limitations in educational and employment opportunities, exclusions in economic and social activities, and impairments in physical and psychosocial function. Although the concept of IBD-related disability is a long-term treatment end point in the updated Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) treatment guideline, it has received limited attention in the literature. This review article explores an etiological framework of the physical and psychosocial aspects that contribute to IBD-related disability. We also explore the impact of IBD-related disability on the direct and indirect costs of IBD. Lastly, we present the available evidence for interventions with the potential to improve function and reduce IBD-related disability.

The association between parental chronic physical illness and adolescent functional somatic symptoms

BACKGROUND

Previous studies have found that adolescents with a chronically ill parent may experience more internalizing problems. It is less clear if this association is sex-related, and whether it is specific for functional somatic symptoms (FSSs) or concerns other internalizing or externalizing problems.

METHODS

In a prospective cohort of adolescents, oversampled on emotional and behavioral problems (n = 841; mean age 14.9 years), we examined the association between parental chronic illness and adolescent's FSSs, and internalizing and externalizing problems. Adolescent's internalizing and externalizing symptoms were measured using the Youth Self Report; parental chronic physical illness was reported during an interview. Associations were tested using linear regression analyses taking into account socio-demographic confounders. We also explored gender-interaction effects.

RESULTS

Having a chronically ill parent (n = 120; 14.3 %) was associated with more FSS in girls (B = 1.05, 95%CI = [0.23, 1.88], p = .013), but not in boys (sex-interaction: p = .013). In girls, an association was also found between parental chronic illness and more internalizing problems (B = 2.68, 95%CI = [0.41, 4.95], p = .021), but this association disappeared when FSSs were excluded from the Internalizing problem scores.

LIMITATIONS

The current study has a cross-sectional design and relied on self-reported parental chronic physical illness what may have induced misclassification.

CONCLUSION

Findings suggest that having a chronically ill parent is associated with more FSSs in adolescent girls and that this association is specific for FSSs instead of general internalizing problems. Girls with a chronically ill parent may profit from interventions to prevent the development of FSSs.

The Mediating Role of Stress Perception in Pathways Linking Achievement Goal Orientation and Depression in Chinese Medical Students

Mental health problems are frequent obstacles in medical students’ careers as doctors. Given that previous studies overlook the mediation of stress perception, the current study expanded previous goal orientation researches by addressing an unexplored mechanism. This study aims to examine the mediational roles of stress perception (perceived stressors and stress-related cognition) on the relationship between achievement goal orientation and depression in medical students. A total of 1,015 Chinese 2-year medical students completed a multi-section questionnaire. Hypotheses were examined by structural equation modeling. The findings suggest that performance-avoidance goal orientation and perceived stressors both demonstrated direct facilitative effects on depression, whereas stress-related cognition demonstrated direct obstructive effects on depression. Both perceived stressors and stress-related cognition mediated the relationship between achievement goal orientation and depression. The findings spark a new perspective on motivational intervention that assist students in adopting mastery-approaching strategy as well as ways of coping with stressful academic situations. Identifying students with achievement goal orientation and providing them with the appropriate supportive services may help them to manage stress and mitigate or prevent depression.

Functional Stroke Symptoms: A Narrative Review and Conceptual Model

Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors. This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.

In-patient liaison psychiatry in the UK

Aims and method

We argue the case for In-patient liaison psychiatry In the UK. We undertook a case note review of the characteristics of a consecutive series of in-patient and day patient admissions to a specialist liaison psychiatry unit in Leeds. We reviewed the literature on in-patient units for the treatment of similar patients, most of which came from the USA.

Results

Physical morbidity was high in the sample. Forty-four per cent had been admitted for physical problems in the year before admission to the unit. Twenty-three per cent were taking five or more drugs for physical disorders at the time of admission, 86% were not in paid employment at the time of admission. Treatment involved integrating treatment for physical Illness, and physical and psychosocial treatments for mental disorder. We identified no reports of in-patient units in the UK doing similar work.

Clinical implications

In-patient liaison psychiatry is neglected in the UK, to the detriment of a small but important group of patients with coexistent severe physical and mental disorder.

Reciprocal Determinism at the Stages of Behavior Change: An Integration of Community, Personal and Behavioral Perspectives

Effective community health education requires theories which combine the perspectives of behavior change at the levels of the individual with those at the levels of the community. Within the framework of reciprocal determinism, a variety of theories and concepts are integrated to understand behavior change at levels of the individual and levels of the community. These concepts are applied at each step in the behavior change process, and categories of intervention are explained within the proposed framework. A variety of specific intervention procedures are generated from the framework for promoting behavior change at each level and stage of change. Such a comprehensive integrated framework holds promise of designing more effective health education programs.

A Controlled Trial of Goal Setting for Long-Term Community Psychiatric Patients

Clinical goal setting is a widely advocated, yet poorly documented technique. This paper describes a controlled trial which was carried out with long-term community psychiatric patients. The experimental group received goal setting in the form of goal attainment scaling (GAS), whilst the control group received social reinforcement. The experimental group had a higher goal score and a significantly higher sessional involvement (p<0.05). The goal categories decided by the clinicians as relevant, differed from those wished by the subjects; the latter subsequently attained only low goal scores. There were no significant differences between the two groups on the work performance or social interaction outcome measures. These differences between the two groups were obtained despite the fact that the subjects of the research were the most intransigent to treatment. It is suggested that goal setting is an independent treatment technique which requires further substantiation, particularly amongst occupational therapists who are covertly or overtly employing the technique. Further research must address the question of identifying the characteristics of patients most likely to benefit from goal setting.

Adolescents with chronic pain and associated functional disability: A descriptive analysis

The purpose of this research was to describe the biopsychosocial characteristics of adolescents with chronic pain and functional disability. Data were obtained from a registry of 100 adolescents (mean age = 15.84, SD = 2.72; 21 males) admitted to an interdisciplinary pain rehabilitation program. Clinician ratings were used to categorize coping and personality styles. The most common chief complaint at admission was limb pain (n = 44), followed by headache (n = 21) and abdominal pain (n = 17). Eighteen patients presented with other types of pain. The most frequent triggers to pain were physical trauma, medical condition or disability, and surgery or another medical procedure. Sleep problems, mental health difficulties, and high academic performance were common. Seven previously identified pain-associated disability factors, including passive or dependent coping style, chronic illness in a parent, personality consistent with alexithymia, unresolved family problems, early pain experiences, learning/developmental difficulties, and perfectionistic personality, were common. Ninety-eight adolescents presented with two or more of these contributing factors. Fifty-six adolescents had four or more of the factors. Adolescents with chronic pain and associated disability presented with numerous biopsychosocial factors that relate to their impairment. The understanding and attention to these factors will be important for successful rehabilitation.

Pain severity and pain catastrophizing predict functional disability in youth with inflammatory bowel disease

BACKGROUND

Abdominal pain is commonly reported by youth with IBD. In a significant subset of youth, pain severity and pain catastrophizing (i.e., unhelpful thoughts related to the pain) may contribute to more negative outcomes and greater impairment in functioning. This study aimed to examine relationships of pain severity and pain catastrophizing with functional disability among a sample of youth with inflammatory bowel disease (IBD).

METHODS

Seventy-five youth aged 11 to 18 years completed ratings of abdominal pain severity, pain catastrophizing, and functional disability using validated measures. Disease activity was rated by treating physicians.

RESULTS

Over half of participants reported abdominal pain in the past two weeks, and pain was present among those with and without clinical disease activity. Nearly one-third of youth reported mild to moderate functional disability. After controlling for gender, pain severity accounted for 15% of the variance in patient functional disability. Moreover, pain catastrophizing contributed significant variance to the prediction of functional disability (approximately 7%) beyond the role of pain severity.

CONCLUSIONS

Greater attention to the role of pain catastrophizing in contributing to functional disability in youth with IBD may be important given that pain-related cognitions are modifiable via intervention.

Exploring the intergenerational transmission of illness behavior: from observations to experimental intervention

BACKGROUND

Functional abdominal pain (FAP) of childhood is characterized by, among other things, pain with no known physiological cause, and family patterns of related disorders have been reported.

PURPOSE

The purpose of this paper is to trace the development of one FAP research program and highlight some of its key findings from observations of interaction patterns to intervention studies designed to test outcomes of altering these patterns.

METHODS

Studies summarized include observational and experimental research.

RESULTS

Parental response to child pain behaviors appears to be a key factor in the development and maintenance of FAP, and intervention which includes targeting changes in parental responses can decrease reports of pain and other illness behaviors.

CONCLUSIONS

Research into FAP can provide valuable information for not only FAP and other unexplained pain conditions, but other medical conditions where environmental responses may play an important role in their etiology and maintenance.

How do patients come to be seen as 'difficult'?: a mixed-methods study in community mental health care

Across all health care settings, certain patients are perceived as 'difficult' by clinicians. This paper's aim is to understand how certain patients come to be perceived and labelled as 'difficult' patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among 'difficult' patients, and three case studies of 'difficult' patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The 'difficult' patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient's behaviours is made. The status of 'difficult' patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into 'difficult' or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients' contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.

Ineffective chronic illness behaviour in a patient with long-term non-psychotic psychiatric illness

This case report offers a different perspective on a patient with a long-term non-psychotic psychiatric disorder that was difficult to specify. The patient, a man in his 50s, was unable to profit from outpatient treatment and became increasingly dependent on mental healthcare - which could not be understood based on his history and psychiatric symptoms alone. By separating symptoms from illness behaviour, the negative course of this patient's treatment is analysed. Focusing on ineffective chronic illness behaviour by the patient, and mutual ineffective treatment behaviour by the clinicians, it becomes clear that basic requirements of effective treatment were unmet. By making a proper diagnosis, clarifying expectations and offering a suitable therapy, ineffective illness behaviour was diminished and this 'difficult' case became much easier for both patient and clinicians. The illness behaviour framework offers a useful, systematic tool to analyse difficulties between patients and clinicians beyond psychiatric symptoms or explanations.

Development of an intervention program to increase effective behaviours by patients and clinicians in psychiatric services: Intervention Mapping study

BACKGROUND

Health clinicians perceive certain patients as 'difficult' across all settings, including mental health care. In this area, patients with non-psychotic disorders that become long-term care users may be perceived as obstructing their own recovery or seeking secondary gain. This negative perception of patients results in ineffective responses and low-quality care by health clinicians. Using the concept of illness behaviour, this paper describes the development, implementation, and planned evaluation of a structured intervention aimed at prevention and management of ineffective behaviours by long-term non-psychotic patients and their treating clinicians.

METHODS

The principles of Intervention Mapping were applied to guide the development, implementation, and planned evaluation of the intervention. Qualitative (individual and group interviews), quantitative (survey), and mixed methods (Delphi-procedure) research was used to gain a broad perspective of the problem. Empirical findings, theoretical models, and existing evidence were combined to construct a program tailored to the needs of the target groups.

RESULTS

A structured program to increase effective illness behaviour in long-term non-psychotic patients and effective professional behaviour in their treating clinicians was developed, consisting of three subsequent stages and four substantial components, that is described in detail. Implementation took place and evaluation of the intervention is being carried out.

CONCLUSIONS

Intervention Mapping proved to be a suitable method to develop a structured intervention for a multi-faceted problem in mental health care.

Explaining medically unexplained symptoms-models and mechanisms

We summarize the psychological mechanisms that have been linked to the development and maintenance of medically unexplained symptoms (MUS). Many models postulate that patients with MUS misinterpret physical sensations and show other cognitive abnormalities (e.g., an over-exclusive concept of health) that play a major role in symptom development. While there is strong evidence for the role of cognitive aspects, there is less evidence for their interaction with perceptual features (e.g., perceptual sensitivity, lowered perceptual threshold). Modern neuroimaging techniques show that the expectation of symptoms leads to the activation of brain areas corresponding to symptom perception, while distraction from symptoms reduces brain activity in perception areas. The frequently postulated monocausal organic attribution for physical sensations by patients with MUS needs to be modified, as many patients report multiple symptom attributions, including psychological. Symptom attributions and causal models depend on memorized concepts, and so memory processes need to be investigated in more detail. Aberrations in memory processes not only offer a link to understanding perceptual processes, but are also involved in doctor-patient interaction. This encounter is characterized by unsuccessful medical reassurance, which again involves memory processes. We conclude that psychological mechanisms such as expectation, distraction, and memory processes need to be integrated with biological models to aid understanding of MUS.

Social learning contributions to the etiology and treatment of functional abdominal pain and inflammatory bowel disease in children and adults

This paper reviews empirical work on cognitive and social learning contributions to the etiology and treatment of illness behavior associated with functional abdominal pain and inflammatory bowel disease. A particular emphasis is placed on randomized controlled trials, the majority of which are multi-modal in orientation, incorporating elements of cognitive behavioral therapy, social learning, and relaxation. Based on this review, we offer methodological and clinical suggestions: (1) Research investigations should include adequate sample sizes, long-term follow-up assessments, and a credible, active control group. (2) Standard gastrointestinal practice should include, when appropriate, learning opportunities for patients and family members, for example, instruction regarding the encouragement of wellness behavior.

Current Directions in the Treatment of Hypochondriasis

Hypochondriasis was once considered treatment resistant. Recent studies, however, suggest that several interventions can be effective. This article presents a narrative review of psychosocial and pharmacologic treatments for hypochondriasis, supplemented by a meta-analysis of treatments to identify the most promising interventions. Findings suggest that cognitive behavior therapy is the most effective treatment for hypochondriasis. Fluoxetine also is promising, although the long-term effects of this and other medications remain to be examined. Psychoeducation appears to be sufficient for mild hypochondriasis. Future research on the mechanisms of hypochondriasis may shed light on how we can improve treatments, particularly for severe cases, which are least likely to benefit from psychosocial and drug interventions.

Cognitive Behavior Therapy for the Treatment of Recurrent Abdominal Pain

This article outlines the rationale and use of cognitive behavior therapy in the treatment of the gastrointestinal symptoms and illness behavior associated with Recurrent Abdominal Pain (RAP), often described as the childhood variant of IBS. It begins with a conceptualization of the social learning perspective of RAP, and then covers the relationship between childhood social learning and adult and childhood illness behavior. Studies that have utilized a cognitive behavior therapy approach for treating adult pain are summarized. Finally, specific cognitive behavior therapy trials for treating RAP, as well as moderators of treatment effectiveness, are discussed.

Tailoring cognitive-behavioral treatment for cancer pain

Though it has been shown that cancer patients report cognitive, behavioral, and physiologic responses to pain, little attention has been paid to the benefits of cognitive-behavioral therapy (CBT) protocols tailored to patient characteristics. To determine whether a profile-tailored CBT treatment program was more effective than either standard CBT or usual care in changing outcomes for patients with cancer-related pain, 131 patients receiving treatment at four sites were randomly assigned to standard CBT, profile-tailored CBT, or usual care. CBT patients attended five 50-minute treatment sessions. When compared to standard CBT patients, profile-tailored CBT patients experienced substantial improvement from baseline to immediately post-intervention in worst pain, least pain, less interference of pain with sleep, and less confusion. From baseline to one-month post-intervention, profile-tailored patients saw greater improvement in less interference of pain with activities, walking, relationships, and sleep; less composite pain interference; and less mobility and confusion symptom distress. Standard CBT and usual care patients experienced little change. Compared to profile-tailored CBT patients, standard CBT patients showed greater improvement at six-months post-intervention with less average pain, less pain now, better bowel patterns, lower summary symptom distress, better mental quality of life, and greater improvement in Karnofsky performance status; usual care patients showed little change. More research is needed to refine the matching of cognitive-behavioral treatments to psychophysiologic patient profiles, and to determine a treatment period that does not burden those patients too fatigued to participate in a five-week program. Delivery of CBT by home visits, phone, or Internet needs to be explored further.

Developmental predictors of somatic symptoms in adolescents of parents with HIV: a 12-month follow-up

Adolescents of parents with HIV provide a test for proposed risk factors for somatic symptoms. This study prospectively examined family and developmental predictors of somatic symptoms in a high-risk community sample. A longitudinal latent variable model predicted adolescent somatization scores from the Brief Symptom Inventory 12 months after baseline assessment of 211 parent-adolescent pairs. In this cohort, somatic symptoms during adolescence persisted over time (p <.001) and were predicted by female gender (p <.05). In addition, (1). parental distress over pain predicted adolescent somatic symptoms at baseline and follow-up (p <.001), (2). adolescents who experienced their parents as highly rejecting reported more somatic symptoms at follow-up (p <.001), and (3). school problems correlated with somatic symptoms (p <.001), as well as parental rejection (p <.001), at baseline. These findings underscore potential relationships among parental illness, parent-child relationships, and somatic distress. Adolescents with school problems are particularly vulnerable, at least in the short run. These data support a family-based approach to treatment programs for adolescents with increased levels of somatic distress.

A management model for pediatric somatization

Medically unexplained physical symptoms are common in pediatric settings, though little systematic research is available to guide the development of treatment efforts for pediatric somatization and somatoform disorders. This paper presents a management model for pediatric somatization based on principles distilled from the available pediatric and adult literature. Careful assessment, frank presentation of the diagnosis, and a cognitive-behavioral and rehabilitative approach are emphasized, along with aggressive psychiatric treatment of comorbid psychopathology. Well-designed empirical studies of intervention are needed that should examine efficacy as well as the relationship between symptomatic improvement, functional improvement, and comorbid anxiety and depressive symptoms.

Case study: negative reinforcement and behavioral management of conversion disorder

Behavioral interventions have been advocated for conversion disorder, but controlled trials are lacking. The authors report the case of a 12-year-old boy with conversion disorder after 3 months of persistent right arm pain and immobility whose symptoms rapidly resolved after an outpatient behavioral intervention using negative reinforcement. The importance of careful assessment, frank discussion of the diagnosis, patient and family psychoeducation, and a rehabilitative mindset are emphasized. Negative reinforcement may be a powerful tool in the management of pediatric conversion disorder, with the potential to reduce parental anxiety and prevent unnecessary physical assessments and interventions.

Functional disability in adolescents and young adults with symptoms of irritable bowel syndrome: the role of academic, social, and athletic competence

OBJECTIVE

To examine perceived academic, social, and athletic competence as potential moderators of the relation between symptoms of irritable bowel syndrome (IBS) and functional disability in adolescents and young adults with a history of recurrent abdominal pain (RAP).

METHODS

We assessed IBS symptoms, competence, and disability by telephone interview in RAP patients five years following their medical evaluation.

RESULTS

For both male and female subjects, the relation between symptoms and disability was stronger at lower levels of perceived academic competence. Furthermore, among females, the relation between symptoms and disability was stronger at lower levels of perceived social competence; among males, the relation was stronger at lower levels of perceived athletic competence.

CONCLUSIONS

Perceived competence moderated the relation between IBS symptoms and functional disability. Interventions designed to enhance patient competence in various roles may be useful in reducing disability among adolescents and young adults with symptoms of IBS.

Psychosomatic problems and stress in adolescence

Psychosomatic problems are common in adolescents, and stress frequently plays a role in their development and maintenance. Armed with an understanding of the stressors experienced by adolescents, the individual's vulnerabilities and competencies and their level of social support, the physician can systematically assess each of these factors. Once the assessment is complete, a management plan can be formulated to address the particular psychosomatic problem. Symptom relief, stress reduction, and promotion of competence are important interventions that can be initiated by the primary care physician. When referrals are made for counseling and other stress management techniques, the primary care physician should maintain contact with the patient and family and remain an integral part of the management team. Incorporating brief discussions about the potential role of stress in health and illness into anticipatory guidance sessions may also help prevent the development of psychosomatic problems in adolescents.

Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model

The objective of this study was to evaluate the effect of a short cognitive behavioural group therapy programme for somatization disorder in primary care. The treatment model was focused on patient education and stress relaxation. A controlled and prospective study design was used with repeated assessments of the patients' perception of their psychosocial problems, psychological distress and medication usage. The results were analysed up to 6 months after treatment and showed the treated patients to be moderately but significantly improved with respect to physical illness and somatic preoccupation, hypochondriasis, and medication usage. In a control group of untreated patients no such improvements were observed. In summary, the short group treatment programme used in this study may be beneficial for patients with somatization disorders. With some modifications it might be useful to practitioners in primary care for the management of psychosomatic disorders.

Reactive effects of diary self-assessment in chronic pain patients

Several studies of experimental and acute clinical pain have indicated reactive effects of self-assessment on pain intensity and tolerance. A recent study of chronic pain patients (vonBaeyer 1994), however, failed to show these effects. The present investigation sought to determine whether reactive effects can be produced in chronic pain patients by an intensive self-assessment protocol. Using the methodology of ecological momentary assessment (EMA; Stone and Shiffman 1994), thirty-five chronic rheumatoid arthritis patients completed diaries of pain and mood seven times a day for 1 wk. Eighteen patients were included in the final sample because they responded to at least half of the number of hourly prompts for each of the 7 days. Using repeated measures analysis of the daily means, no significant effects of time were found for any measures. Reactive effects that result in an average change in pain levels over time, therefore, do not appear to be produced by intensive self-assessment in a naturalistic context. Results are discussed in terms of cognitive and behavioral theories of pain reactivity.

The use of contingency management in the treatment of a geriatric nursing home patient with psychogenic vomiting

A substantial percentage of nursing home residents evidence psychosocial and behavioral problems. However, surprisingly little is known about how effectively to treat geriatric patients with behavioral problems. The present study reports the behavioral treatment of a patient with psychogenic vomiting. The patient was successfully treated by changing the contingencies of her illness behavior and of behavior associated with rehabilitation goals. This indicates the importance of nursing home staff attending to the operants of illness behavior. Specifically, independent behavior should be rewarded by praise and attention and illness behavior should be ignored in terms of attention.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.

The influence of life stress, personality, and learning history on illness behavior

Previous research has suggested that prior learning experiences and current reinforcement contingencies account for a substantial portion of the variance in illness behaviors. The present study examined the role of other variables (e.g., stimulus and organismic variables). Two hundred and sixty four college students completed questionnaires that included the Life Events Survey, Hassles Scale, Hypochondriasis Scale (MMPI), Illness Attitude Scale, and a Medical Problems Survey. It emerged that social learning variables accounted for significant portions of variance in symptom reporting behavior even after other demographic, current stressor, and personality variables were accounted for. The advantages of using behavioral assessment models for conceptualizing influential variables is highlighted and directions for future research discussed.

Diagnosis and treatments of hypochondriacal syndromes

There are controversies in the literature about the diagnosis and most appropriate treatment of hypochondriasis. The author offers guidelines for diagnosis of hypochondriacal syndromes that have not been adequately dealt with in the literature and discusses the choice of treatments.

Inpatient treatment of persistent somatization

Patients with disabling, persistent somatization pose significant challenges in clinical management. This study describes 92 patients treated on an inpatient psychosomatic medicine unit for persistent somatization. The most important factor in defining clinically significant subgroups of these patients was mood. Compared with depressed somatizing patients, nondepressed somatizing patients had chronic illnesses of early onset, had symptoms that were not correlated with current life stressors, and were generally unresponsive to treatment. There were few clinical predictors of treatment outcome apart from the duration of symptoms, the presence of mood disturbance, and a history of stable interpersonal relationships.

Monosymptomatic hypochondriacal psychosis: belief of contracting rabies

The authors describe a forty-one-year-old female with possible monosymptomatic hypochondriacal psychosis (MHP): a delusional belief that she had contracted rabies. This is the first report of this type of delusion in MHP. The patient failed to respond to multiple somatic therapies and finally made a serious suicide attempt. The authors discuss the reasons for the failed treatment and suggest a sequential protocol for treatment of MHP based on the current literature.

Non-institutional treatment of chronic pain by field management: an outcome study with comparison group

Field management, through the use of specially trained field consultants, is a mechanism by which interdisciplinary interventions can be implemented in non-institutional settings. Management of the real environmental determinants (home, work, social) of pain and disability should improve the effectiveness of behaviorally based interventions and make these treatments more accessible. Over a 6 year period, 261 patients having various chronic somatic complaints (e.g., pain, fatigue, gastrointestinal complaints) underwent interdisciplinary outpatient treatment based on medical and behavioral sciences. Comparison of patients having field management with patients receiving office-based treatment found a significantly greater reduction in disability with field management. 84% of field managed patients had a successful outcome as defined by: (a) return to regular work, or (b) reduced limitations on work, exercise, and daily living activities, depending on functional status at assessment. Only 61% of patients with office-based treatment were successful. Compliance, defined as the frequency with which treatment was mutually terminated, was significantly higher with field management. The availability of long-term disability benefits was highly predictive of a poorer outcome. However, field management remained effective for improving functional status regardless of the availability of benefits. Finally, determination of the cost of non-institutional treatment indicated that field management is a cost-effective modality. Implications of these findings for the treatment of disability in chronic pain and other chronic illness syndromes are discussed.

An inpatient programme for persistent somatizers

Somatization, defined as a transient or persistent tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them, represents a common problem in clinical practice. A comprehensive inpatient rehabilitation program for somatizing patients has been developed at the Clarke Institute in Toronto and is described in detail. It involves concurrent application of psychiatric, psychological, social, and medical therapies.

Effects of time-limited vs unlimited compensation on pain behavior and treatment outcome in low back pain patients

A common theme in the pain literature is that worker's compensation reinforces pain behavior and adversely influences treatment outcome of chronic pain patients. This study compared 110 chronic low back pain males divided into three groups: 44 receiving no compensation, 27 receiving time-limited worker's compensation, and 39 receiving unlimited social security disability benefits. All patients participated in a multimodal treatment program (e.g. nerve blocks, transcutaneous electrical nerve stimulation, relaxation training, biofeedback). Physician ratings of pain behavior and self-report measures of pain characteristics, activity level, and medication intake were gathered pretreatment; self-report measures were collected again approximately one year following treatment. The results showed disability patients to have a higher percentage of physician rated symptom dramatization and pain behavior and a greater usage of medication compared with the non-compensation and time-limited worker's compensation patients. At follow-up, no between group differences were found on measures of pain intensity, medication usage and activity. In general, however, more worker's compensation and non-compensation patients who were initially not working had returned to work at the time of follow-up compared with the disability patients. These results suggest that time-limited compensation may not affect treatment outcome or interfere with return-to-work chances while unlimited compensation may adversely influence the probability that patients will return to work. These findings support the notion that worker's compensation patients receiving time-limited financial benefits do not necessarily represent a 'problem' subgroup of chronic pain patients.

Pain and families. I. Etiology, maintenance, and psychosocial impact

This is the first part of a two-part extended review on the interdependency between chronic pain and families. This paper will address the role of the family in the etiology and maintenance of chronic pain and will describe the reciprocal impact of chronic pain on families. Different conceptualizations of the role of the family and the available empirical evidence related to 3 central questions, namely, 'do families play an etiological role in chronic pain?,' 'does the family maintain the chronic pain problem?,' and 'is there a negative impact of chronic pain on the family?' will be critically examined. The second, companion paper will address the issue of the inclusion of family members in the assessment and treatment of chronic pain. Finally, recommendations for future research will be made.

Chronic pain and the family: a review

This paper reviews the literature on chronic pain patients and their families. The review focuses on family and marital variables correlated with pain, conceptualizations of the family's role in maintaining pain, reports of family treatment and follow-up studies of the family's impact on treatment. Although research in this field is generally weak methodologically, and the mechanisms whereby the family affects chronic pain are still little understood, the authors conclude that family characteristics and behaviors contribute strongly to a chronic pain problem and they have a significant influence on treatment outcome.

Patterns of symptom report on the Brief Symptom Inventory

Three global indices of symptomatology summarize results of the Brief Symptom Inventory. This study attended to the relationship between global indices of symptom enumeration and symptom severity. Among profiles of 850 adult outpatients, a strong relationship existed between style of reporting symptoms, emphasizing number or intensity, and prominence of certain symptom dimensions. Patients reporting numerous low-grade symptoms were high on Somatization and Phobic Anxiety. Those with more intense focal symptoms were high on Depression and Anxiety. An explanation of results is offered by referring to features likely common among associated symptom dimensions.