Journal
of
Psychosomatic
Research,
THE
Vol.
20,
DETERMINANTS J.G.
309-316.
OF
INGHAM
ROYAL
pp.
and
Pergamon
ILLNESS P.McC.
Press,
1976.
Printed
in
Great
Britain
DECLARATION MILLER
MRC UNIT EDINBURGH HOSPITAL EDINBURGH
Sociological discussions of illness behaviour have usually sought general explanations irrespective of the particular illness concerned. Is this really possible? Doesn't illness behaviour depend quite a lot upon the kind of illness and its severity? Illness is difficult to define satisfactorily but we can say certain things about it: (1)
Illness is very often an internal source of unpleasant subjective states - pains, nausea, general feelings of When it is, it can be a primary cause malaise, etc. of illness behaviour.
(2)
Illness states arising
(3)
To complicate matters further, somatic illnesses can be seen interpretable as goal-seeking according to which theoretical
can also be a result of unpleasant arising from external sources, e.g. from threatening life-events.
subjective the anxiety
some mental or psychoas adaptations, or conditioned responses orientation is preferred.
Illness behaviour although often caused primarily by illness can also occur in its absence, Like illness itself, it may result from external stress and it may be a form of adaptation. Even when illness is the primary causes the resulting behaviour may be modified by sources of stress other than the illness itself and by adaptation to problems of living other than those presented by the illness itself. One of the most frequent and socially important items of illness behaviour is going to the doctor, The sort of illness one sees in the vast majority of patients in the general practitioner's surgery depends very much for its recognition and diagnosis upon what the patient says. A person goes to his doctor because he is in a state of distress, or he feels threatened by something potentially distressing or it is a form of goal-seeking behaviour. A layman's commonsense view is that the primary cause of a consultation is illness and that a goal-seeking consultation is malingering. This is clearly an over-simplification but he may be right in one respect* The distress associated with a given illness is probably the most influential single determinant of consulting. It is possible to account for
309
310
J. G.
Ingham
and P. McC.
consulting behaviour to some severity. We have tried to and how much variance remains severity has been taken into
Miller
extent by measured symptom find out how far this is true to be explained when symptom account.
If a further explanation is necessary, where are we to look for it? Social scientists interested in illness behaviour tend to talk about reasons for adopting the 'sick-role*, the different meanings that symptoms have for different people, attitudes towards doctors, ways of coping with threatening situations, ways of expressing internal emotional states and All of these are likely to be so on (l)9 (2), (3). important, but how much relative weight should be placed upon them in accounting for consulting behaviour, as compared with symptom severity? This is an important question for research into the nature of an many reasons. For example, illness is usually concentrated on declared cases - people who have already come under medical surveillance, If the act of declaration depends markedly upon factors not directly connected with the illness, declared cases are an atypical group and we can be misled into believing that what is typical of the group is also typical of the illness. A
study
of
self-referrals
to
GeneralPractitioners
We know already that many symptoms, indeed many illnesses, seem to be surprisingly frequent amongst the non-declared population (4), but until we quantify severity carefully it is difficult to know how well symptom severity can account for illness declaration, how well it can discriminate between self-declared cases and others. It could simply be that the undeclared symptoms are less severe. We have tried to clarify this point by comparing symptom declared consulters with non-consulters. Patients consulting with new episodes of illness at a general practitioner's surgery, were asked to declare their symptoms - the ones they were going to mention to the doctor - and were subsequently compared on symptom severity with a control group of people who had not had a recent consultation. We were trying to see how far you could get in discriminating consulters from non-consulters, using self-ratings of declared symptoms and nothing else. It was necessary to select a limited number of symptoms because of the time needed to administer scales with the necessary discriminative power. The psychological symptoms chosen were anxiety, depression, irritability and fatigue; the physical symptoms were backache, headache, palpitations, The work has to be focussed dizziness and breathlessness. on symptoms, rather than diagnosed illnesses or syndromes, because it is concerned with self-declaration by the patient. In consulting a doctor p people declare themselves as ill, usually with specific symptoms rather than with a disease that they can recognise and label. Methods The sample were first
of consulters attenders at
comprised the general
172 patients practitioner's
all
of whom surgery,
The
Determinants
of Illness Declaration
311
with new episodes of illness, on selected days. One day was For chosen at random from each of ten consecutive weeks. each consulter a control who had not attended during the previous three months and of the same age and sex was The response rate for selected from the practice list. Controls who consulters was 95% and for controls 89%. refused or could not be interviewed for some other reason were replaced by others selected in the same way. The consulters were interviewed twice, once briefly in the surgery on arrival for consultation and then at home as soon as possible afterwards. Controls were all interviewed once at home. Results of symptom assessment will be reported methods:first and these were obtained bj the following
(1)
(2)
In
the
(consulters
only)
A brief mentioned
check list of symptoms to the doctor.
At
(both
home
a b I1 Both
surgery
types
scale
were
to be
groups)
Pair comparison Visual analogue of
which
are
symptom symptom described
scales. scales. elsewhere
(5).
Results There are many ways of comparing frequency distributions of two groups. The one we have selected as the most useful for our purpose is percentage overlap (5). This is defined as the percentage of individuals from both groups who could be matched on the variable concerned, with a member of the other group, given groups of equal size. With unimodal distributions this is equal to twice the overall percentage misclassification rate, with the cut-off at the point where the two distribution curves cross0 We obtained a score on every symptom scale for each of our subjects , patients and controls alike, and the distributions of scores and combinations of scores can be compared between Before looking at patients who declared specific groups. symptoms, it is interesting to see whether it is possible to discriminate controls from consulters as a whole, whether or not they declared any of our selected symptoms to the doctor. The figures are shown at the top of table 1 for total physical symptom score and total psychological symptom score. It is quite clear that neither score discriminates well; there is a large amount of overlap. This was to be expected. People consult their doctors with any of a wide range of symptoms and we are only investigating a few of them. To see whether a better discrimination could specific sub-groups, consultera were divided consulted with one or more physical symptoms and one or more psychological symptoms only
be obtained with into those who only (N - 47) (N = 10).
312
J. G.
Ingham
and P. McC.
Miller
The figures in table 1 show that this gave quite a worthwhile reduction in overlap for physical consulters on physical symptom scores and for psychological consulters on Even these figures, however, psychological symptom scores., could hardly be said to show successful discrimination between groups. TABLE
All
lo
PERCENTAGE OVERLAP IN STANDARD SCORES
Consulters
(N I 172)
and
DISTRIBUTIONS OF ON SYMPTOM SCALES
Controls
(N I
Physical symptom score Psychological symptom score Consulters Controls
(only hysical (N I 172 P
172) 84.3% 90.8%
symptoms
declared
Physical symptom score Psychological symptom score Consulters (only psychological and Controls (N = 172)
SUMMED
N II 47)
and
73.5% 98.6% symptoms
declared
Physical symptom score Psychological symptom score
N I 10)
99.0% 79.7%
Table 2 shows what happens when one attempts to discriminate consulters declaring specific symptoms from controls, using as discriminators severity scales of the symptoms concerned. Some of the samples are small but the percentage overlap figures are clearly much lower than those in table 1. People who consult with a given symptom can be quite well discriminated from non-consulting controls using self-rated Considering the small severity of the same symptom. it is interesting that the two types of scale give numbers, similar results. TABLE
2.
PERCENTAGE AND
OVERLAP BETWEEN SELF-DECLARED CONTROLS (Ncontrols = 172)
N
groups
PairComparison Scales
Visual Analogue Scales
24 29
Backache Fatigue Anxiety Headache Depression Irritability Palpitations Dizziness Breathlessness *The
*
cases
CASES
4: 10 9 5 18 21 of
cases
51% 42% 43% 54% are
not
mutually
62% 28% 45% 41% 51% 45% exclusive.
The
Determinants
313
of Illness Declaration
Although as predicted single symptom discrimination was there is still a lot of overlap to be explained. better, Undoubtedly discriminances could be improved somewhat by using more than one symptom (our samples were too small to It is not likely that the improvement would attempt this). look for variables We must now, in fact, be very great. outside the illness domain if we are to improve on these figures0 There is a bewildering number of possibilities, some of them very simple and obvious ones like distance from availability of a babysitter, availability of a surgery, substitute at work, etc. These will obviously have to be considered. We would suggest that the most interesting psychological and social variables in this context can probably be divided into three main categories:(l)
Situational particularly'
variables those of
external to a threatening
(2)
External threats, medical
(3)
The subject's own internal resources the threats involved and making use that are available.
resources available which could be seen services.
to as
the subject, nature,
help in meeting alternatives to
the
for coping with of the resources
Our studies of these variables are at a very early stage but there is some evidence on certain aspects of each category. This evidence was obtained from a sub-sample of 34 consulters and their matched controls who were given a more extensive home interview than the rest of the sample. These people were asked about:(a)
The number of threatening life events the three months prior to interview, based on the techniques of Brown and (6) and (7).
(b)
The existence of at least one close confidant and number of less close friends and acquaintances available. Both were assessed by a questionnaire specially devised for this study (8).
(c)
An assessment of the subject's willingness to talk about his problems using a method of self-disclosure similar to that devised by Jourard et al (9) and (10).
The most interesting results are indications that social have a role as modifiers of yet have enough evidence to
besetting them in assessed by a method his collaborators
relate to life events. support and self-disclosure the effects of stress but support such a statement.
the
There may we do
The number of threatening life events in the previous three months was the only variable that discriminated significantly between consulters as a whole and the controls, the consulters having had more threatening life events (Wilcoxon matched pairs P < .Ol). Is this because threatening life events
not
314
J. G.
Ingham
and P. McC.
Miller
make people ill or is it that they are more likely to consult the doctor with a given severity of illness? To answer this we must look first at the relationship between threatening life events and symptoms. The correlations for consulters and controls separately are shown in table 3. There are highly significant correlations in the consulting sample for psychological symptoms, but not in controls. There is very little evidence of correlation for physical symptoms in either It looks as though some people have reacted to group. threatening circumstances by developing more severe psychological symptoms and that these are the people who have consulted their doctors. TAELE
3.
CORRELATIONS SYMPTOM
Anxiety Depression Irritability Fatigue Backache Headache Palpitations Dizziness Breathlessness "P **p
BETWEEN THREATENING SCALES (PAIR COMPARISON ANALOGUE COMBINED)
LIFE EVENTS AND VISUAL
Consulters (N = 34)
Controls (N = 34)
.74** .61** *51** .43*
.34* .33 .21 -13
.03 .ll .26 01.6 -.03
AND
.20 .45** -04 -024 001
< .05 c .OOl
This is shown clearly in table 4 where consulters have been sub-divided into those with at least one threatening life event and those without. Nearly half of these consulters did have at least one threatening life event in the previous three months and their mean psychological symptom score was high compared with those without threatening life events. The difference was much less marked for physical symptoms. One question remaining is whether the consulters with threatening life events who reported psychological symptoms on the symptom scales also declared them to the doctor. The last two columns of table 4 show the total numbers of psychological and physical symptoms declared in each group. It seems that the psychological symptoms suffered by these people are indeed declared and there is little evidence of physical symptoms being used as "tickets of admission" as has sometimes been suggested.
The
TABLE
4.
Determinants
SYMPTOMS
Consulters
N
With threatening life events
16
Without threatening life events
18
AND
THREATENING
Mean* Psychological symptom Score
Mean Physical symptom Score
2.06
-0.44
*t for Difference Symptom Score =
315
of Illness Declaration
LIFE
EVENTS Number of Psychological Symptoms Declared
Number of Physical symptoms Declared
-0,03
10
8
-0.70
4
14
in Mean 2.44 (P
Psychological c.05)
Conciusions 1,
Self-rated discriminator practitioners
symptom severity is not a very of people who consult their from those who do not.
good general
2.
Threatening life-events amongst consulters than
3.
Consulters who have experienced threatening life tend to report more severe psychological symptoms or non-consulting controls. other consulters,
4.
The stressed consulters with psychological symptoms do tend to declare their psychological symptoms (anxiety, etc.) to the doctor. depression,
are significantly more amongst non-consulting
frequent controls. events than
being based on a small pilot These conclusions are tentative, sample, but they are sufficiently convincing to justify our The consulters who seeking confirmation on a larger sample. have experienced stressful life events and who report Amongst psychological symptoms could be an important group. them we would expect to find psychoneuroses in the making, As suggested at the outset, consulters are not a homogeneous Here perhaps is one important sub-group, those who group. What is consult their doctors following a period of stress. it that differentiates them from other people with threat and symptoms who do not consult their doctors? It is hoped that the next stage of this enquiry will answer that question in addition to confirming the present findings. Acknowledgements We owe a great deal to Drs and also to their patients time and thereby made this
Alexander, who gave research
Paterson and very generously possible.
Whitley, of their
316
J. G.
Ingham
and P. McC.
Miller
REFERENCES 1.
2.
3. 4.
5.
6.
7.
8. 9. 10.
Mechanic, D., The Concept of Illness Behaviour, J. Chron. Dis., 15, 189 (1962). Robinson, D., Patients, Practitioners and Medical Care: Aspects of Medical Sociology, William Heinemann Medical Books (1973). Sick Role in a Setting of Shuval, Judith T., The Comprehensive Medical Care, Medical Care, X, 1 (1972). Wadsworth, M.E.J., Butterfield, W.J.H. and Blaney, R. Health and Sickness: the Choice of Treatment. Perception of Illness and Use of Services in an Urban Community, Tavistock Publications Ltd. (1971). Ingham, J.G. and Miller, P.McC., The Concept of Prevalence applied to Psychiatric Disorders and Symptoms, Psychological Medicine, in press (1976). Brown, G.W., Sklair, F., Harris, T.O. and Birley, J.L.T., Life-events and Psychiatric Disorders. Part 1: some methodological issues, Psychological Medicine, 3, 74 (1973). Brown, G.W., Bhrolchain, M.N. and Harris, T.O., Social class and psychiatric disturbance among women in an urban population, Sociology 9, 225 (1975);onfidants Miller, P.McC. and Ingham, ;.G., Friends, and Symptoms, Social Psychiatry, in press (1976). Cozby, P.C., Self-disclosure: A Literature Review, Psycholopical Bulletin, 79, 73 (1973). An Experimental Jourard, Sidney M., Self-disclosure: Analysis of the Transparent Self, Wiley-Interscience (1971).
of
Psychosomatic
Research,
THE
Vol.
20,
DETERMINANTS J.G.
309-316.
OF
INGHAM
ROYAL
pp.
and
Pergamon
ILLNESS P.McC.
Press,
1976.
Printed
in
Great
Britain
DECLARATION MILLER
MRC UNIT EDINBURGH HOSPITAL EDINBURGH
Sociological discussions of illness behaviour have usually sought general explanations irrespective of the particular illness concerned. Is this really possible? Doesn't illness behaviour depend quite a lot upon the kind of illness and its severity? Illness is difficult to define satisfactorily but we can say certain things about it: (1)
Illness is very often an internal source of unpleasant subjective states - pains, nausea, general feelings of When it is, it can be a primary cause malaise, etc. of illness behaviour.
(2)
Illness states arising
(3)
To complicate matters further, somatic illnesses can be seen interpretable as goal-seeking according to which theoretical
can also be a result of unpleasant arising from external sources, e.g. from threatening life-events.
subjective the anxiety
some mental or psychoas adaptations, or conditioned responses orientation is preferred.
Illness behaviour although often caused primarily by illness can also occur in its absence, Like illness itself, it may result from external stress and it may be a form of adaptation. Even when illness is the primary causes the resulting behaviour may be modified by sources of stress other than the illness itself and by adaptation to problems of living other than those presented by the illness itself. One of the most frequent and socially important items of illness behaviour is going to the doctor, The sort of illness one sees in the vast majority of patients in the general practitioner's surgery depends very much for its recognition and diagnosis upon what the patient says. A person goes to his doctor because he is in a state of distress, or he feels threatened by something potentially distressing or it is a form of goal-seeking behaviour. A layman's commonsense view is that the primary cause of a consultation is illness and that a goal-seeking consultation is malingering. This is clearly an over-simplification but he may be right in one respect* The distress associated with a given illness is probably the most influential single determinant of consulting. It is possible to account for
309
310
J. G.
Ingham
and P. McC.
consulting behaviour to some severity. We have tried to and how much variance remains severity has been taken into
Miller
extent by measured symptom find out how far this is true to be explained when symptom account.
If a further explanation is necessary, where are we to look for it? Social scientists interested in illness behaviour tend to talk about reasons for adopting the 'sick-role*, the different meanings that symptoms have for different people, attitudes towards doctors, ways of coping with threatening situations, ways of expressing internal emotional states and All of these are likely to be so on (l)9 (2), (3). important, but how much relative weight should be placed upon them in accounting for consulting behaviour, as compared with symptom severity? This is an important question for research into the nature of an many reasons. For example, illness is usually concentrated on declared cases - people who have already come under medical surveillance, If the act of declaration depends markedly upon factors not directly connected with the illness, declared cases are an atypical group and we can be misled into believing that what is typical of the group is also typical of the illness. A
study
of
self-referrals
to
GeneralPractitioners
We know already that many symptoms, indeed many illnesses, seem to be surprisingly frequent amongst the non-declared population (4), but until we quantify severity carefully it is difficult to know how well symptom severity can account for illness declaration, how well it can discriminate between self-declared cases and others. It could simply be that the undeclared symptoms are less severe. We have tried to clarify this point by comparing symptom declared consulters with non-consulters. Patients consulting with new episodes of illness at a general practitioner's surgery, were asked to declare their symptoms - the ones they were going to mention to the doctor - and were subsequently compared on symptom severity with a control group of people who had not had a recent consultation. We were trying to see how far you could get in discriminating consulters from non-consulters, using self-ratings of declared symptoms and nothing else. It was necessary to select a limited number of symptoms because of the time needed to administer scales with the necessary discriminative power. The psychological symptoms chosen were anxiety, depression, irritability and fatigue; the physical symptoms were backache, headache, palpitations, The work has to be focussed dizziness and breathlessness. on symptoms, rather than diagnosed illnesses or syndromes, because it is concerned with self-declaration by the patient. In consulting a doctor p people declare themselves as ill, usually with specific symptoms rather than with a disease that they can recognise and label. Methods The sample were first
of consulters attenders at
comprised the general
172 patients practitioner's
all
of whom surgery,
The
Determinants
of Illness Declaration
311
with new episodes of illness, on selected days. One day was For chosen at random from each of ten consecutive weeks. each consulter a control who had not attended during the previous three months and of the same age and sex was The response rate for selected from the practice list. Controls who consulters was 95% and for controls 89%. refused or could not be interviewed for some other reason were replaced by others selected in the same way. The consulters were interviewed twice, once briefly in the surgery on arrival for consultation and then at home as soon as possible afterwards. Controls were all interviewed once at home. Results of symptom assessment will be reported methods:first and these were obtained bj the following
(1)
(2)
In
the
(consulters
only)
A brief mentioned
check list of symptoms to the doctor.
At
(both
home
a b I1 Both
surgery
types
scale
were
to be
groups)
Pair comparison Visual analogue of
which
are
symptom symptom described
scales. scales. elsewhere
(5).
Results There are many ways of comparing frequency distributions of two groups. The one we have selected as the most useful for our purpose is percentage overlap (5). This is defined as the percentage of individuals from both groups who could be matched on the variable concerned, with a member of the other group, given groups of equal size. With unimodal distributions this is equal to twice the overall percentage misclassification rate, with the cut-off at the point where the two distribution curves cross0 We obtained a score on every symptom scale for each of our subjects , patients and controls alike, and the distributions of scores and combinations of scores can be compared between Before looking at patients who declared specific groups. symptoms, it is interesting to see whether it is possible to discriminate controls from consulters as a whole, whether or not they declared any of our selected symptoms to the doctor. The figures are shown at the top of table 1 for total physical symptom score and total psychological symptom score. It is quite clear that neither score discriminates well; there is a large amount of overlap. This was to be expected. People consult their doctors with any of a wide range of symptoms and we are only investigating a few of them. To see whether a better discrimination could specific sub-groups, consultera were divided consulted with one or more physical symptoms and one or more psychological symptoms only
be obtained with into those who only (N - 47) (N = 10).
312
J. G.
Ingham
and P. McC.
Miller
The figures in table 1 show that this gave quite a worthwhile reduction in overlap for physical consulters on physical symptom scores and for psychological consulters on Even these figures, however, psychological symptom scores., could hardly be said to show successful discrimination between groups. TABLE
All
lo
PERCENTAGE OVERLAP IN STANDARD SCORES
Consulters
(N I 172)
and
DISTRIBUTIONS OF ON SYMPTOM SCALES
Controls
(N I
Physical symptom score Psychological symptom score Consulters Controls
(only hysical (N I 172 P
172) 84.3% 90.8%
symptoms
declared
Physical symptom score Psychological symptom score Consulters (only psychological and Controls (N = 172)
SUMMED
N II 47)
and
73.5% 98.6% symptoms
declared
Physical symptom score Psychological symptom score
N I 10)
99.0% 79.7%
Table 2 shows what happens when one attempts to discriminate consulters declaring specific symptoms from controls, using as discriminators severity scales of the symptoms concerned. Some of the samples are small but the percentage overlap figures are clearly much lower than those in table 1. People who consult with a given symptom can be quite well discriminated from non-consulting controls using self-rated Considering the small severity of the same symptom. it is interesting that the two types of scale give numbers, similar results. TABLE
2.
PERCENTAGE AND
OVERLAP BETWEEN SELF-DECLARED CONTROLS (Ncontrols = 172)
N
groups
PairComparison Scales
Visual Analogue Scales
24 29
Backache Fatigue Anxiety Headache Depression Irritability Palpitations Dizziness Breathlessness *The
*
cases
CASES
4: 10 9 5 18 21 of
cases
51% 42% 43% 54% are
not
mutually
62% 28% 45% 41% 51% 45% exclusive.
The
Determinants
313
of Illness Declaration
Although as predicted single symptom discrimination was there is still a lot of overlap to be explained. better, Undoubtedly discriminances could be improved somewhat by using more than one symptom (our samples were too small to It is not likely that the improvement would attempt this). look for variables We must now, in fact, be very great. outside the illness domain if we are to improve on these figures0 There is a bewildering number of possibilities, some of them very simple and obvious ones like distance from availability of a babysitter, availability of a surgery, substitute at work, etc. These will obviously have to be considered. We would suggest that the most interesting psychological and social variables in this context can probably be divided into three main categories:(l)
Situational particularly'
variables those of
external to a threatening
(2)
External threats, medical
(3)
The subject's own internal resources the threats involved and making use that are available.
resources available which could be seen services.
to as
the subject, nature,
help in meeting alternatives to
the
for coping with of the resources
Our studies of these variables are at a very early stage but there is some evidence on certain aspects of each category. This evidence was obtained from a sub-sample of 34 consulters and their matched controls who were given a more extensive home interview than the rest of the sample. These people were asked about:(a)
The number of threatening life events the three months prior to interview, based on the techniques of Brown and (6) and (7).
(b)
The existence of at least one close confidant and number of less close friends and acquaintances available. Both were assessed by a questionnaire specially devised for this study (8).
(c)
An assessment of the subject's willingness to talk about his problems using a method of self-disclosure similar to that devised by Jourard et al (9) and (10).
The most interesting results are indications that social have a role as modifiers of yet have enough evidence to
besetting them in assessed by a method his collaborators
relate to life events. support and self-disclosure the effects of stress but support such a statement.
the
There may we do
The number of threatening life events in the previous three months was the only variable that discriminated significantly between consulters as a whole and the controls, the consulters having had more threatening life events (Wilcoxon matched pairs P < .Ol). Is this because threatening life events
not
314
J. G.
Ingham
and P. McC.
Miller
make people ill or is it that they are more likely to consult the doctor with a given severity of illness? To answer this we must look first at the relationship between threatening life events and symptoms. The correlations for consulters and controls separately are shown in table 3. There are highly significant correlations in the consulting sample for psychological symptoms, but not in controls. There is very little evidence of correlation for physical symptoms in either It looks as though some people have reacted to group. threatening circumstances by developing more severe psychological symptoms and that these are the people who have consulted their doctors. TAELE
3.
CORRELATIONS SYMPTOM
Anxiety Depression Irritability Fatigue Backache Headache Palpitations Dizziness Breathlessness "P **p
BETWEEN THREATENING SCALES (PAIR COMPARISON ANALOGUE COMBINED)
LIFE EVENTS AND VISUAL
Consulters (N = 34)
Controls (N = 34)
.74** .61** *51** .43*
.34* .33 .21 -13
.03 .ll .26 01.6 -.03
AND
.20 .45** -04 -024 001
< .05 c .OOl
This is shown clearly in table 4 where consulters have been sub-divided into those with at least one threatening life event and those without. Nearly half of these consulters did have at least one threatening life event in the previous three months and their mean psychological symptom score was high compared with those without threatening life events. The difference was much less marked for physical symptoms. One question remaining is whether the consulters with threatening life events who reported psychological symptoms on the symptom scales also declared them to the doctor. The last two columns of table 4 show the total numbers of psychological and physical symptoms declared in each group. It seems that the psychological symptoms suffered by these people are indeed declared and there is little evidence of physical symptoms being used as "tickets of admission" as has sometimes been suggested.
The
TABLE
4.
Determinants
SYMPTOMS
Consulters
N
With threatening life events
16
Without threatening life events
18
AND
THREATENING
Mean* Psychological symptom Score
Mean Physical symptom Score
2.06
-0.44
*t for Difference Symptom Score =
315
of Illness Declaration
LIFE
EVENTS Number of Psychological Symptoms Declared
Number of Physical symptoms Declared
-0,03
10
8
-0.70
4
14
in Mean 2.44 (P
Psychological c.05)
Conciusions 1,
Self-rated discriminator practitioners
symptom severity is not a very of people who consult their from those who do not.
good general
2.
Threatening life-events amongst consulters than
3.
Consulters who have experienced threatening life tend to report more severe psychological symptoms or non-consulting controls. other consulters,
4.
The stressed consulters with psychological symptoms do tend to declare their psychological symptoms (anxiety, etc.) to the doctor. depression,
are significantly more amongst non-consulting
frequent controls. events than
being based on a small pilot These conclusions are tentative, sample, but they are sufficiently convincing to justify our The consulters who seeking confirmation on a larger sample. have experienced stressful life events and who report Amongst psychological symptoms could be an important group. them we would expect to find psychoneuroses in the making, As suggested at the outset, consulters are not a homogeneous Here perhaps is one important sub-group, those who group. What is consult their doctors following a period of stress. it that differentiates them from other people with threat and symptoms who do not consult their doctors? It is hoped that the next stage of this enquiry will answer that question in addition to confirming the present findings. Acknowledgements We owe a great deal to Drs and also to their patients time and thereby made this
Alexander, who gave research
Paterson and very generously possible.
Whitley, of their
316
J. G.
Ingham
and P. McC.
Miller
REFERENCES 1.
2.
3. 4.
5.
6.
7.
8. 9. 10.
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