Multiple medically unexplained physical symptoms and health care utilization: outcome of psychological intervention and patient-related predictors of change.

OBJECTIVES: To test the effect of psychological intervention on multiple medically unexplained physical symptoms, psychological symptoms, and health care utilization in addition to medical care as usual. To identify patient-related predictors of change in symptoms and care utilization. METHODS: In a randomized controlled trial, subjects were assigned to one of two conditions: psychological intervention by a qualified therapist plus care as usual by a general practitioner (GP) or care as usual only. Participants (N=98) were administered a standardized interview and several outcome measures at intake and after 6 months and 12 months after intake. GPs rated medically unexplained and explained symptoms and consultations over a period of 1 1/2 years. RESULTS: ANOVAs for repeated measures showed that self-reported and GP-registered unexplained physical symptoms decreased from pretest to posttest to follow-up. Psychological symptoms and consultations decreased from pretest to posttest. GP-registered explained symptoms did not decrease. However, intervention and control groups did not differ in symptom reduction. Path analysis revealed two paths to a decrease in self-reported unexplained physical symptoms: from more negative affectivity via more psychological attribution and more pretreatment anxiety, and from more somatic attribution via more psychological attribution and more pretreatment anxiety. CONCLUSION: Intervention and control groups did not differ in symptom reduction. Reduction of self-reported medically unexplained symptoms was well predicted by patient-related symptom perception variables, whereas the prediction of change in registered symptoms and consultations requires a different model.

Predicting medically unexplained physical symptoms and health care utilization. A symptom-perception approach.

OBJECTIVES: The present study investigated the contribution of demographic characteristics (age, gender, socioeconomic status [SES]) and symptom-perception variables to unexplained physical symptoms and health care utilization. In addition, the consequences of the use of four frequently applied symptom-detection methods for relations among study variables were examined. METHOD: A group of 101 men and women were administered a standardized interview and several questionnaires. Their general practitioners (GPs) rated (un)explained symptoms and consultations over the previous year. RESULTS: Path analyses showed that direct and indirect effects on symptoms and GP consultations depend on method of symptom detection, the largest difference being between self-reported symptoms and registered symptoms. The model including self-reported common symptoms demonstrated the direct and indirect effects of the symptom-perception variables: chronic disease, negative affectivity, selective attention to bodily sensations, and somatic attribution. In the model including registered symptoms, only chronic disease and SES showed effects on symptoms and GP consultations. CONCLUSION: This study demonstrates the usefulness of a symptom-perception approach to the experience of unexplained symptoms, the importance of selection of a symptom-detection method, and the need for different models for the explanation of daily experienced symptoms and their presentation in health care.

Preparing children for venepuncture. The effect of an integrated intervention on distress before and during venepuncture.

Venepuncture for routine blood sampling is a very distressing experience for a considerable number of children. Not only do they express high levels of distress during venepuncture but also in anticipation of the procedure. Therefore, prevention or reduction of distress should focus on both phases of the procedure. To this end, three preparation elements were combined: local anaesthesia of the skin, provision of sensory and procedural information, and involvement of the parent. In order to test the effect of this integrated procedure on the distress reactions of young children before as well as during venepuncture, 31 children were randomly assigned to one of two conditions: preparation or no preparation. Independent raters, who were blind to group assignments, scored segments of the videotaped behaviour of the children, according to the Groninger Distress Scale. Prepared children displayed significantly less distress before and during venepuncture than not-prepared children, regardless of their gender, ethnical origin, age, injection history, and the tension of their parent.

The Impact-on-Family Scale: a test of invariance across culture.

OBJECTIVE: To test the cultural invariance of the Impact-on-Family Scale in order to make cross-cultural comparisons. METHODS: The Italian version of the scale was administered to mothers of children with chronic illnesses. Factorial invariance was examined to investigate whether the four factors found with the original United States (U.S.) scale could be replicated. RESULTS: The results clearly demonstrate the replicability of the first three factors, Financial Burden, Familial/Social Impact, and Personal Strain. In addition, internal consistency and the homogeneity of the items of the corresponding scales are satisfactory. However, the fourth factor, Mastery, could not be replicated, and the reliability of the corresponding scale is poor. Italian mothers scored significantly lower on the Financial Burden and on the Familial/Social Impact dimension, compared to the American sample. CONCLUSIONS: Three of the four factors of the Impact-on-Family Scale are useful for cross-cultural comparisons between U.S. and Italian samples.

Gender differences in physical symptoms and illness behavior. A health diary study.

Recent studies on symptom perception have highlighted the role of psychological factors, such as mood states and external involvement, in physical symptom reporting. To date, the consistently found higher physical symptom reports in women have not been studied from this perspective. The present study aimed to investigate the psychological determinants of gender differences in physical symptoms and illness behavior on a daily basis. During four adjacent weeks, a healthy primary care sample of 92 women and 61 men kept health diaries, containing scales for physical symptoms, illness behavior, external information and positive and negative mood. The daily health records showed the typical gender difference in physical symptoms, but not in illness behavior. Negative mood was found to be the strongest predictor of physical symptoms. Physical symptoms in turn were the strongest predictor of illness behavior. The modest gender difference in physical symptoms disappeared after controlling for positive and negative mood. Thus, mood states seem to mediate gender differences in symptom reporting.

The influence of respiratory sounds on breathlessness in children with asthma: a symptom-perception approach.

The discordance between the objective and subjective symptoms of asthma has major effects on proper medication and management. In 2 studies the influence of respiratory sounds in the process of symptom perception underlying breathlessness was investigated in children aged 7-17 years. In Experiment 1, asthmatic wheezing sounds were recorded in 16 children during histamine-induced airway obstruction. Breathlessness correlated significantly with rank order of amount of wheezing, but not with lung function. In Experiment 2, after standardized physical exercise, 45 asthmatic and 45 nonasthmatic children were randomly assigned to (a) false feedback of wheezing, (b) quiet respiratory sounds, or (c) no sound. Asthmatic children reported significantly more breathlessness in the 1st versus the 3rd condition. In conclusion, many asthmatic children were easily influenced by wheezing in their estimation of asthma severity, reflected in breathlessness.

Sex differences in physical symptoms: the contribution of symptom perception theory.

Health surveys, studies on physical symptom reporting, and medical registration of physical complaints find consistent sex differences in symptom reporting, with women having the higher rates. By and large, this female excess of physical symptoms is independent from the symptom measure, response format and time frame used, and the population under study. As most studies concern healthy individuals, the sex difference can not simply be attributed to a greater physical morbidity in women. In this paper we propose a number of explanations for this phenomenon, based on a biopsychosocial perspective on symptom perception. We discuss a symptom perception model that brings together factors and processes from the extant literature which are thought to affect symptom reporting, such as somatic information, selection of information through attention and distraction, attribution of somatic sensations, and the personality factors somatisation and negative affectivity. Finally, we discuss the explanations for sex differences in physical symptoms that arise from the model.

[Sex differences in perceived health]. / Sekseverschillen in gezondheidsbeleving.

Findings from health surveys show that women report more physical complaints than men. These sex differences have been attributed to physical, psychological and social factors. In a large-scale morbidity registration project in general practice in Nijmegen (the Netherlands) women reported more 'medically unexplained symptoms' to their GP, but especially had more sex-specific (gynaecological) problems and consultations for preventive purposes. An empirical study among 173 healthy GP patients showed that the general tendency to report physical symptoms (somatization) is higher in women than in men. The higher symptom score in women can be explained with the symptom perception model: women have more negative affectivity, more selective attention for their bodies and less distraction from the surroundings, which enhances somatization. The differences in perceived health are the result of the (sex-specific) way in which men and women perceive and interpret their symptoms and the (sex-specific) way in which they act upon them by consulting their GP.

Gender perspectives and quality of care: towards appropriate and adequate health care for women.

Gender inequalities in health are a consequence of the basic inequality between men and women in many societies. Despite the importance of socio-economic factors, women's health is also greatly affected by the extent and quality of health services available to them. Both non-governmental women's organizations and feminist health researchers have in recent years identified major gender inequalities in access to services and in the way men and women are treated by the health care system. Firstly, although women are major health care users as well as providers, they are under-represented in decision-making in health care. Secondly, no justice is done in general to existing differences in position and needs of women and men in defining quality of health care, i.e. gender aspects. Among women's organizations, there is general agreement that "gender sensitive health care should be available, accessible, affordable, appropriate and acceptable". In addition, health care for women should be adequate and not depart from a male model of health and illness. In this paper, we pay attention to inappropriate health care for women on the one hand, as illustrated by the increasing medicalization of women's reproductive life [menstruation, menopause, pregnancy and childbirth and (in)fertility]. On the other hand, we discuss gender bias in the management of serious, life-threatening diseases such as cardiovascular disease, lung cancer, and kidney failure, as a form of inadequate care. These examples are followed by a global vision on quality of care from a gender perspective, as formulated by the women's health care movement in the Netherlands and at the Fourth International Conference on Women in Beijing. If anything, the recommendations agreed upon in Beijing will have to ensure the consolidation and enhancement of good quality health care for women around the world. The final discussion, attempts to give some general recommendations for achieving more adequate (gender sensitive) and appropriate (non-medicalizing) health care for women. These recommendations pertain to health and health care research, policy, education, and organization from a women's perspective.

The influence of lung function information on self-reports of dyspnea by children with asthma.

Studied the influence of actual and false peak flow (PEF) information on dyspnea (breathlessness) in two experiments, each with 30 children with and 30 without asthma (7-17 years). Dyspnea, PEF, and lung function were measured before and after standardized physical exercise. Dyspnea was measured with a visual analog scale. PEF was measured with a peak flow meter and used for manipulation of dyspnea. The first experiment showed that the relationship between dyspnea and lung function was not stronger when children had knowledge of PEF values. The second experiment revealed that asthmatic children who received false feedback of 30% below the actual PEF reported significantly more dyspnea. Implications for the management of asthma are discussed.

The capacity of children with and without asthma to detect external resistive loads on breathing.

Clinical observations and research with adults consistently showed that subjective symptoms of asthma poorly reflect actual airway obstruction. The lack of accurate symptom perception poses a problem for medication and management of asthma. The accuracy of airflow detection was studied in 46 children with and 46 without asthma (aged 7-18 years). They breathed through a facemask and responded to load stimuli of different intensity. Sessions consisted of 10 blocks of 5 min, each with 10 stimuli presented. Experiment 1: Loads of increasing intensity presented to 36 children with and 36 without asthma. Seven asthmatics had a reliable detection threshold (just noticeable difference, jnd) analogous to approximately equal to 64% fall in forced expiratory volume in 1 sec (FEV1). Ten normal controls had a jnd of approximately 39% fall. Experiment 2: Loads randomly presented to 10 children with and 10 without asthma. Four asthmatics had a jnd of approximately equal to 64% fall in FEV1. Six normal controls had a jnd of approximately equal to 39% fall. The results demonstrated that children generally were poorly perceiving load stimuli and that asthmatics were less accurate.

Male and female health problems in general practice: the differential impact of social position and social roles.

Sex, social position and social roles have been identified as important health predictors. Moreover, various social variables have been found to bear differently upon female as compared to male health. This study analyses data from a large-scale registration project in general practice (the Continuous Morbidity Registration), pertaining to the medical diagnoses of nearly 10,000 patients over a five year period. The effects of sex, social class, marital and parental status on a number of distinct categories of health problems were established, and a possible differential impact of social position and social roles on male and female health was explored. Categories of health problems studied were 'overall health problems', 'sex specific conditions', 'symptoms without disease', 'prevention and diagnostics' and 'trauma'. Sex and, above all, social class were identified as important predictors of most categories of health problems, especially during the reproductive period of life. Marital status and parental status did not contribute substantially to most types of health problems. Rates of prevention and diagnostics, sex specific conditions and total number of health problems could to a certain extent be predicted by the four sociodemographic variables, as opposed to trauma rates and symptoms without disease rates. Social class appeared the only variable with a substantially different effect on male vs female rates of sex specific conditions, prevention and diagnostics and trauma, but not so for overall health problems and symptoms without disease. Marital status and parental status did not differ significantly in their effect on male vs female health. Results illustrate that differentiation of the health variable into categories of health problems elucidates the relationship between sex, social variables and health.

Characteristics of wheeze during histamine-induced airways obstruction in children with asthma.

BACKGROUND: An automated system has been developed for the detection of sound patterns suggestive of airways obstruction in long term recordings. The first step, presented here, was tracheal sound recording during histamine-induced airways obstruction. METHODS: The tracheal sounds of 29 children aged 8-19 years with asthma were recorded during airways obstruction caused by histamine inhalation using a system for continuous respiratory telemetry and computer analysis. Sound patterns were analysed, classified, and related to airways obstruction measured by lung function tests based on the forced expiratory volume in one second (FEV1). RESULTS: Five sound patterns were identified, one dominant sensitive and four specific to a fall in FEV1 of > 20%. The presence of at least one of three specific sound patterns during unforced respiration predicted a fall in FEV1 of > 20% in 87.5% of the subjects. The inspiratory and expiratory sound patterns were almost equally informative of airways obstruction. CONCLUSIONS: Wheezes can be differentiated with more precision than is currently accepted. Tracheal sound patterns are sensitive and specific predictors of histamine-induced airways obstruction. These patterns are neither invariably nor proportionally related to the results of lung function testing. However, they can be used for detection of airways obstruction on the basis of their presence or absence.

Male and female morbidity in general practice: the nature of sex differences.

Outcomes from large scale health surveys suggest women's morbidity and medical care utilization to be higher than men's. Survey findings have often been questioned on methodological grounds, a main criticism being the subjective nature of the data on which the alleged sex differences are based. Moreover, health differences vary with the type of illness (behavior) that is assessed. Instead of asking subjects about their illness experiences, we performed analyses on data derived from a continuous registration of morbidity as presented in four general practices in the Netherlands. Information was obtained on physician diagnoses of 4723 male and 4963 female patients of all ages enlisted in the four practices from 1984 to 1988. To gain insight in the nature of sex differences, four diagnostic categories were distinguished (sex specific conditions, trauma, symptoms without disease, and prevention and diagnostics). Data on mean number of diagnoses, sex ratio's and proportions of overall morbidity are presented for separate age-groups. In addition, the contribution of each diagnostic category to overall female excess morbidity was computed, for age-groups. Results show that over 40% of the significantly higher overall female morbidity is accounted for by gynaecological and obstetrical diagnoses, and more than a quarter could be explained by prevention and diagnostics. In contrast with the often alleged female excess of 'vague' or psychosomatic symptoms, these accounted for less than 20% of the overall sex difference.

Symptom sensitivity and sex differences in physical morbidity: a review of health surveys in the United States and The Netherlands.

Health surveys have found higher female morbidity rates, as reflected by indices such as general health status, number of acute conditions or physical symptoms and medical care utilization. Such findings can lead to the conclusion that women are the "sicker sex" in terms of objective health status. However, the size of the sex difference varies with the different indices used to operationalize the morbidity concept. Apart from sex specific conditions, the female morbidity excess seems most substantial with regard to general health status, acute and mild chronic conditions and physical symptoms. Findings from a large health survey in the Netherlands, presented in this article, confirm this picture. Some major methodological sources of bias, that have been held responsible for part of the sex differences found in health surveys, such as the poor definition of the morbidity concept and aspects of the data collection process, are discussed. One explanation for the higher morbidity of women, i.e., the differential perception of physical symptoms by men and women, is elaborated in more detail. The authors suggest that part of the sex differences found in health surveys can be explained by a higher female symptom sensitivity, defined as a readiness to perceive physical sensations as symptoms of illness. Research supporting this symptom sensitivity hypothesis is reviewed and explanations are given. It is suggested that further research on sex differences in morbidity should control for methodological sources of sex bias and should focus explicitly on differences in the perception of physical symptoms by men and women.