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Biomedical subjects

A J Barsky

Publications and source records attributed to A J Barsky.

At least 19 recordsLinked to original sources
PubMed1998

A prospective 4- to 5-year study of DSM-III-R hypochondriasis.

BACKGROUND: Although hypochondriasis is generally thought to be a chronic and stable condition with a relatively low remission rate, this disorder remains understudied. METHODS: This is a 4- to 5-year prospective case-control study of DSM-III-R hypochondriasis. Medical outpatients meeting DSM diagnostic criteria for hypochondriasis completed an extensive research battery assessing hypochondriacal symptoms, medical and psychiatric comorbidity, functional status and role impairment, and medical care. A comparison group of nonhypochondriacal patients from the same setting underwent the same battery. Four to 5 years later, both cohorts were re-interviewed. RESULTS: One hundred twenty hypochondriacal and 133 nonhypochondriacal comparison patients were originally studied. Follow-up was obtained on 73.5% (n = 186) of all patients. At follow-up, the hypochondriacal sample was significantly (P<.001) less hypochondriacal and had less somatization (P<.001) and disability than at inception, but 63.5% (n = 54) still met DSM-III-R diagnostic criteria. When compared with the comparison group using repeated measures multivariate analysis of variance, these changes remained statistically significant (P<.0001). Changes in medical and psychiatric comorbidity did not differ between the 2 groups. When hypochondriacal patients who did and did not meet diagnostic criteria at follow-up were compared, the latter had significantly less disease conviction (P<.05) and somatization (P<.01) at inception, and their incidence of major medical illness during the follow-up period was significantly (P<.05) greater. CONCLUSIONS: Hypochondriacal patients show a considerable decline in symptoms and improvement in role functioning over 4 to 5 years but two thirds of them still meet diagnostic criteria. Hypochondriasis, therefore, carries a very substantial, long-term burden of morbidity, functional impairment, and personal distress.

Activities of Daily Living↗
PubMed1996

Somatized psychiatric disorder presenting as palpitations.

BACKGROUND: Psychiatric disorder is underdiagnosed in primary care practice, often because it is somatized and the patient reports only physical symptoms. Palpitations are among the symptoms that often are somatized. METHODS: We studied prospectively 125 consecutive medical outpatients referred for ambulatory electrocardiographic monitoring to evaluate a chief complaint of palpitations. They completed an in-person research interview at the time of monitoring and a telephone follow-up interview 3 months later. The referring physicians completed questionnaires about their patients before receiving the results of the monitoring and again 3 months later. RESULTS: Forty-three patients had clinically significant cardiac arrhythmias. Twenty-four (29%) of the remaining 82 patients had a current psychiatric disorder, and 20 of these patients (83%) had major depression or panic disorder. These patients were significantly younger and more disabled, somatized more, and had more hypochondriacal concerns about their health than did patients who had no psychiatric disorder. Their palpitations were more likely to last longer than 15 minutes, were accompanied by more ancillary symptoms, and were described as more intense. At 3-month follow-up, about 90% of the patients in both groups continued to experience palpitations. Symptoms of somatization, hypochondriacal concerns, and impairment of intermediate activities had improved in both groups, but remained higher in patients with psychiatric disorder than in patients without psychiatric disorder. During the follow-up interval, patients with psychiatric disorder had more emergency department visits. The physicians of patients with psychiatric disorder were more likely to ascribe the palpitations to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatment were referred or started on psychotropic medication. CONCLUSIONS: Physicians are aware of a psychiatric component to the clinical presentation of palpitation, but this observation does not result in psychiatric treatment or referral in most cases.

Adult↗
PubMed1996

Predictors of persistent palpitations and continued medical utilization.

BACKGROUND: The aim of this study was to determine the predictors of persistent palpitations and continued medical utilization in a sample of medical patients referred for ambulatory electrocardiographic monitoring. METHODS: A prospective telephone follow-up was conducted with patients who had undergone ambulatory electrocardiographic monitoring 3 months earlier. At inception, patients completed in-person interviews and self-report questionnaires, assessing somatization, hypochondriacal attitudes, bodily amplification (high degree of sensitivity to bodily sensations), and two types of life stress (minor daily irritants and major life changes). At follow-up, patients completed a structured interview about their clinical course, palpitations, and utilization of medical care during the interval. RESULTS: At 3-month follow-up, 55 of the inception cohort of 67 patients were interviewed again. The mean severity of palpitations for the entire sample declined significantly, but 46 (83.6%) patients continued to experience their presenting symptoms. Stepwise multiple linear regression revealed that the interaction of bodily amplification and daily life stress at inception uniquely explained 10.0% of the variance in palpitation severity at follow-up. A four-step model composed of these two interaction terms and age and education level accounted for 21.4% of the variance in palpitations. The medical utilization findings are complementary in that the interaction of amplification and daily irritants at baseline predicted the number of unscheduled medical visits over the subsequent 3 months. The total number of ventricular premature contractions occurring during ambulatory monitoring was not a significant predictor of palpitations. CONCLUSIONS: Palpitations are more persistent in persons who are both highly sensitive to bodily sensations and who experience a greater number of minor daily irritants. The existence of either predictor alone is not sufficient to perpetrate this functional somatic symptom; it requires the combination of these predictors.

Aged↗
PubMed1995

Somatization and medicalization in the era of managed care.

Somatization, the reporting of somatic symptoms that have no pathophysiological explanation, appears to be increasing as sociocultural currents reduce the public's tolerance of mild symptoms and benign infirmities and lower the threshold for seeking medical attention for such complaints. These trends coincide with a progressive medicalization of physical distress in which uncomfortable bodily states and isolated symptoms are reclassified as diseases for which medical treatment is sought. Somatization and medicalization are likely to become more problematic in the era of managed care. Under capitation, providers will have greater incentives to reduce utilization, and somatizing patients may feel forced to express their "disease" in more urgent and exaggerated terms in order to gain access to the physician. In addition, prepaid subscribers will suffer little financial disincentive to seek medical attention for relatively minor complaints; therefore, they are likely to increase the demand for physician consultation. This situation suggests an urgent need to improve the management of somatizing patients. Innovative consultative, behavioral, and educational interventions are now available. In addition, medical professionals should greet the process of medicalization with considerable caution and educate the public more about the normative presence of symptoms and bodily distress in healthy people. Additional research is needed into somatization and its relationship to the demand for medical care. In an era of managed care, increased attention should be devoted to understanding and controlling the demand for care, a large portion of which is symptom driven.

Capitation Fee↗
PubMed1995

The clinical course of palpitations in medical outpatients.

OBJECTIVE: The aim of this study was to describe the longitudinal course of patients who were referred for ambulatory electrocardiographic monitoring because of palpitations. METHODS: A prospective, follow-up examination was conducted of patients who had been studied 6 months previously when referred for monitoring. The inception cohort consisted of 145 consecutive patients with palpitations and 70 asymptomatic, nonpatient volunteers. At follow-up, the patients completed the same research battery as at inception, consisting of structured interviews and self-report questionnaires. These assessed cardiac symptoms, medical care use, role impairment, somatization, hypochondriacal fears and beliefs, and psychiatric disorder. RESULTS: At 6 months' follow-up, 130 patients with palpitations (89.7% of the original cohort) and 69 nonpatients (98.6%) were reinterviewed. Eighty-four percent of the patients had recurrent palpitations during the 6-month follow-up period. At follow-up, patients with palpitations scored significantly higher than the comparison group on measures of cardiac symptoms and role impairment, and had made more physician visits in the preceding 6 months. They had a higher prevalence of panic disorder and more psychopathologic symptoms, somatized more, and were more hypochondriacal. Psychiatric symptoms and the tendency to amplify bodily sensation, measured at inception, were significant but modest predictors of subsequent palpitations. There was considerable confusion and misunderstanding among patients as to the findings of their ambulatory electrocardiogram and the presence or absence of panic disorder. CONCLUSIONS: Patients with palpitations remain symptomatic and functionally impaired and have increased rates of physician visits in the 6 months following Holter monitoring. They also continue to have elevated rates of panic disorder and to evidence some confusion about the cause of their symptoms.

Persons with Disabilities↗
PubMed1995

Accurate awareness of heartbeat in hypochondriacal and non-hypochondriacal patients.

We measured the accurate awareness of resting heartbeat in a sample of medical out-patients meeting DSM-III-R criteria for hypochondriasis (n = 60), and in a comparison group of non-hypochondriacal patients (n = 60) from the same general medical clinic. Patients also completed subjective self-report ratings of their sensitivity to benign bodily sensation and of functional somatic symptoms. Hypochondriacal patients did not differ significantly from non-hypochondriacal patients in their accurate awareness of heartbeat. They did, however, consider themselves more sensitive to benign bodily sensation and report more functional somatic symptoms. Within each sample, the only statistically significant association found was a negative correlation (r = -0.32, p = 0.025) between heartbeat awareness and the severity of hypochondriacal symptoms among the hypochondriacal patients. These results suggest that hypochondriacs may not be more accurately aware of normal cardiac activity, and therefore that hypochondriacal somatic complaints may not result from an unusually fine discriminative ability to detect normal physiological sensations that non-hypochondriacal individuals do not perceive.

Adult↗
PubMed1994

Relationship between patient self-ratings and physician ratings of general health, depression, and anxiety.

OBJECTIVE: To examine the relationship between patient self-ratings and physician ratings of general health, depression, and anxiety and patient and physician ratings in comparison to Diagnostic Interview Schedule (DIS) diagnoses of depression and anxiety. DESIGN: Observational study. SETTING: A general medical outpatient clinic. PATIENTS: Clinic attendees. METHOD: Consecutive clinic attendees on randomly selected days completed a self-reported screening questionnaire for hypochondriasis, composed of the Whiteley Index and the Somatic Symptom Inventory. A random sample of patients (N = 79), 95% of whom had scores below the cutoff for hypochondriasis (n = 75) and 5% of whom had scores at or above the cutoff for hypochondriasis (N = 4), returned at a later date to complete a research battery consisting of self-reported questionnaires, structured and semistructured interviews, and a structured interview for diagnoses of anxiety and depression based on the DIS, which used criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. OUTCOME MEASURES: Responses to questionnaires and interviews. RESULTS: Agreement between patients and physicians was statistically significant concerning patients' physical health, depression, and anxiety. Based on one question, both physicians' and patients' ratings of depression and anxiety compared favorably with DIS diagnoses. By means of receiver operating characteristics analysis, values for the areas under the curve and their SEs were as follows: for depression, 0.789 +/- 0.075 for patient self-ratings and 0.825 +/- 0.054 for physician ratings; for anxiety, 0.734 +/- 0.058 for patient self-ratings and 0.667 +/- 0.065 for physician ratings. CONCLUSION: One simple question about a patient's status with respect to depression or anxiety is sufficient to detect these disorders with high sensitivity and specificity, yielding values comparable to those yielded by instruments consisting of many items. Asking patients to rate their own levels of depression and anxiety may constitute one portion of the family physician's diagnostic assessment for these conditions.

Anxiety Disorders↗
PubMed1994

Hypochondriasis and panic disorder. Boundary and overlap.

BACKGROUND: To determine the nosological and phenomenological overlap and boundaries between panic disorder and hypochondriasis, we compared the symptoms, disability, comorbidity, and medical care of primary care patients with each diagnosis. METHODS: Patients with DSM-III-R panic disorder were recruited by screening consecutive primary care clinic attenders and then administering a structured diagnostic interview for panic disorder. Patients also completed self-report questionnaires, and their primary care physicians completed questionnaires about them. They were then compared with patients with DSM-III-R hypochondriasis from the same setting who had been studied previously. RESULTS: One thousand six hundred thirty-four patients were screened; 135 (71.0% of the 190 eligible patients) completed the research battery; 100 met lifetime panic disorder criteria. Twenty-five of these had comorbid hypochondriasis. Those without comorbid hypochondriasis (n = 75) were then compared with patients with hypochondriasis without comorbid panic disorder (n = 51). Patients with panic disorder were less hypochondriacal (P < .001), somatized less (P < .05), were less disabled (P < .001), were more satisfied with their medical care (P < .001), and were rated by their physicians as less help rejecting (P < .05) and less demanding (P < .01). Major depression was more prevalent in the group with panic disorder (66.7% vs 45.1%; P < .05), as were phobias (76.0% vs 37.3%; P < .001), but somatization disorder symptoms (P < .0001) and generalized anxiety disorder were less prevalent (74.5% vs 16.0%; P < .001) in panic disorder than was hypochondriasis. CONCLUSIONS: While hypochondriasis and panic disorder co-occur to some extent in a primary care population, the overlap is by no means complete. These patients are phenomenologically and functionally differentiable and distinct and are viewed differently by their primary care physicians.

Adult↗
PubMed1994

Psychiatric disorders in medical outpatients complaining of palpitations.

OBJECTIVE: To determine the prevalence of psychiatric disorders in ambulatory patients undergoing Holter monitoring to evaluate palpitations. DESIGN: Patients referred for 24-hour ambulatory electrocardiographic (ECG) monitoring were studied with a structured diagnostic interview and self-report questionnaires prior to monitoring. SETTING: Holter laboratory of a large academic medical center. PATIENTS AND OTHER PARTICIPANTS: One hundred forty-five consecutive patients complaining of palpitations and 70 asymptomatic non-patient volunteers. OUTCOME MEASURES: DSM-III-R psychiatric diagnoses. RESULTS: Forty-five percent (44.8%) of the participants had at least one lifetime anxiety or depressive disorder and 24.8% had at least one current (one month) disorder. The lifetime prevalence of panic disorder was 27.6%, and that of major depression was 20.8%. Current prevalence rates showed a similar pattern; the current prevalence of panic disorder was 18.6%. Panic disorder and somatization disorder symptoms were significantly more prevalent in the palpitation group than in the general medical clinic at the same hospital. Patients with a psychiatric diagnosis were more likely to report cardiac symptoms during monitoring than were those without psychiatric disorder, and more commonly described their symptoms as "pounding" and reported faintness, lightheadedness, and vertigo. Although cardiac histories and ECG results were no more serious, the patients with psychiatric diagnoses rated their overall health status as significantly worse. CONCLUSIONS: Almost half of palpitation patients referred for Holter monitoring have a psychiatric disorder. More than a fourth have lifetime panic disorder and a fifth have had panic attacks in the month before monitoring.

Adult↗
PubMed1994

The accuracy of symptom reporting by patients complaining of palpitations.

PURPOSE: To examine the relationship between patients' reports of palpitations and documented arrhythmias. PATIENTS AND METHODS: Consecutive patients complaining of palpitations and referred for 24-hour ambulatory electrocardiographic monitoring were studied using self-report questionnaires and a structured diagnostic interview. Electrocardiographic results were subsequently analyzed in conjunction with symptom diaries. Positive predictive value was used to estimate the likelihood that a reported symptom coincided with a documented arrhythmia. Sensitivity was calculated as a measure of the likelihood that an arrhythmia would be detected and reported as a symptom. RESULTS: Positive predictive value was inversely related to somatization, hypochondriacal attitudes, and psychiatric symptoms. It was not related to chronicity of palpitations, previously diagnosed heart disease, more extensive medical care utilization, or clinically significant arrhythmias. Patients were generally insensitive to their arrhythmias, failing to note the vast majority. CONCLUSIONS: Somatizing and hypochondriacal patients are not more sensitive to or accurately aware of subtle changes in cardiac activity, but rather may be expressing a response bias toward reporting somatic and psychologic distress in general. Apparently, patients do not learn to discriminate and detect cardiac activity more accurately as a result of having more medical care or suffering longer with their symptoms.

Adult↗
PubMed1994

Panic disorder, palpitations, and the awareness of cardiac activity.

One hundred forty-five consecutive patients referred for ambulatory electrocardiographic monitoring for the evaluation of palpitations were studied just before monitoring. They were compared with 75 asymptomatic, nonpatient volunteers. The research battery included a structured diagnostic interview, self-report questionnaires, and perceptual tasks measuring awareness of cardiac activity. After monitoring, symptom reports were compared with concurrent electrocardiographic recordings to determine their accuracy. Forty palpitation patients (27.6%) had DSM-III-R lifetime panic disorder, and 27 (18.6%) had current (1-month) panic disorder. Panic patients were significantly more likely to describe their palpitations as "racing" or "pounding" and to have been awakened from sleep by them. They did not have more cardiac arrhythmias during 24-hour, electrocardiographic monitoring, and their symptom reports were significantly less likely to be due to demonstrable cardiac irregularities. They were not more accurately aware of resting heartbeat than nonpanic palpitation patients. They did score higher on self-report measures of somatization, hypochondriasis, and bodily amplification.

Adult↗
PubMed1994

Histories of childhood trauma in adult hypochondriacal patients.

OBJECTIVE: This study examined the childhood histories of trauma, parental attitudes toward health, and physical illness in hypochondriacal adults. METHOD: Sixty outpatients with DSM-III-R hypochondriasis and 60 nonhypochondriacal outpatients from the same general medical clinic were compared. All patients completed the Childhood Traumatic Events Scale and an eight-item questionnaire about childhood illness and health. Medical morbidity was assessed with a medical record audit. RESULTS: Significantly more hypochondriacal than nonhypochondriacal patients reported traumatic sexual contact (28.6% versus 7.3%), physical violence (32.1% versus 7.3%), and major parental upheaval (28.6% versus 9.1%) before the age of 17. These differences remained statistically significant after sociodemographic differences between the groups were controlled for with multivariate regression analysis. The two groups did not differ in the age at which these traumas occurred or in the degree of trauma experienced. Significantly more hypochondriacal patients reported being sick as children and missing school for health reasons, but they did not differ in other measures of childhood illness and parental attitudes toward illness. The two groups had similar levels of aggregate medical morbidity. CONCLUSIONS: Hypochondriacal adults recall more childhood trauma than do nonhypochondriacal patients, even after sociodemographic differences are controlled for. They also recall more childhood illness, although they are not currently more medically sick.

Adolescent↗
PubMed1993

A research agenda for outpatient consultation-liaison psychiatry.

Primary care settings are increasingly important sites for psychiatric research. A broader range of many psychiatric disorders is encountered here than in the mental health arena, and their study will therefore provide us with a more representative picture of the true nature of these disorders. This is also the setting in which to investigate the medical care process itself, including such phenomena as nonadherence with the medical regimen, patient delay before seeking appropriate medical attention, the placebo phenomenon, patient satisfaction, and the nature of the doctor-patient relationship. Much of primary care practice consists of the management and palliation of somatic symptoms, yet the phenomenology of somatic symptoms has barely been investigated. Outpatient psychiatric researchers are in an ideal position to study the entire process of symptom perception, formation, experience, and reporting, including the phenomenon of somatization. However, ambulatory medical settings impose particular constraints and demands upon consultation-liaison researchers. They may be met with indifference and even suspicion, and in turn they too often fail to appreciate the nature of the primary care setting and the research questions that are important to primary care providers, whose interest and involvement must be enlisted from the outset. Consultation-liaison researchers must acquire the substantive skills, knowledge, and techniques that are demanded by this type of research, because this work must be rigorous and of high caliber.

Humans↗
PubMed1993

The perception of cardiac activity in medical outpatients.

This study compared several measures of cardiac perception and related them to patient' spontaneous reports of palpitations. One hundred and forty-five ambulatory patients referred for Holter monitoring for the evaluation of palpitations were compared with 70 asymptomatic nonpatients. Reports of palpitations during monitoring were compared with the ECG to determine whether they coincided with an arrhythmia. Subjects also completed a heartbeat detection task to determine whether they were accurately aware of cardiac systole while at rest. 20.7% of palpitation patients and 4.7% of asymptomatic controls demonstrated an accurate awareness of resting heartbeat (p = 0.01). Performance was unrelated to bodily amplification, somatization, hypochondriacal symptoms, ECG findings, or psychiatric morbidity. 34.3% of palpitation patients reported symptoms that consistently coincided with arrhythmias on ECG. These accurate patients had significantly lower levels of amplification, somatization, hypochondriacal symptoms, and psychiatric morbidity. Accuracy of symptom reporting and accuracy of heartbeat awareness were not statistically associated.(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias, Cardiac↗
PubMed1993

The course of transient hypochondriasis.

OBJECTIVE: This study examined the longitudinal course of patients known to have had a previous episode of transient hypochondriasis. METHOD: Twenty-two transiently hypochondriacal patients and 24 nonhypochondriacal patients from the same general medical clinic were reexamined after an average of 22 months with the use of self-report questionnaires, structured diagnostic interviews, and medical record review. RESULTS: The hypochondriacal patients continued to manifest significantly more hypochondriacal symptoms, more somatization, and more psychopathological symptoms at follow-up. They also reported significantly more amplification of bodily sensations and more functional disability and utilized more medical care. These differences persisted after control for differences in medical morbidity and marital status. Only one hypochondriacal patient, however, had a DSM-III-R diagnosis of hypochondriasis at follow-up. Multivariate analyses revealed that the only significant predictors of hypochondriacal symptoms at follow-up were hypochondriacal symptoms and the tendency to amplify bodily sensations at the baseline evaluation. CONCLUSIONS: Hypochondriacal symptoms appear to have some temporal stability: patients who experienced hypochondriacal episodes at the beginning of the study were significantly more hypochondriacal 2 years later than comparison patients. They were not, however, any more likely to develop DSM-III-R-defined hypochondriasis. Thus, hypochondriacal symptoms may be distinct from the axis I disorder. The data are also compatible with the hypothesis that preexisting amplification of bodily sensations is an important predictor of subsequent hypochondriacal symptoms.

Ambulatory Care↗