اضطراب سلامتی و ویژگی های مشاوره پزشک عمومی خودشروع کننده

Health anxiety has been hypothesized to lead to a cycle of repeated medical consultations. We investigated the relationship of health anxiety to patients’ frequency of general practitioner visits, and to their expectations about the index visit in 200 general practice attenders. Health anxiety scores declined modestly with age, and were similar in men and women. Frequency of visits rose from 2.6 per year in the lowest decile of health anxiety to 4.2 in the highest (p=0.033). Across the same range, the odds of seeking advice prior to visiting the doctor rose from 0.25 to 0.56 (p=0.034), and the odds of believing that a specialist referral would be needed rose from 0.22 to 0.48 (p=0.008). There was no association between health anxiety and previous referral for investigation of symptoms that had not resulted in a medical diagnosis, nor with attitudes to prescriptions, possibly because there was little variation in either. In this population, absolute levels of health anxiety were low. Nevertheless, within this “normal” range, there was an association between level of health anxiety and frequency of visiting, and with expectations for the index visit. The findings support the health anxiety model as predicting use of services by psychologically normal persons.

There has been concern in many areas of medicine that some patients develop a maladaptive relationship with the medical services, resulting in repeated and unnecessary consultations. Although a small proportion of such patients will have a definable hypochondriacal disorder, most do not meet diagnostic criteria for any psychiatric disorder; however, they are characterized by higher levels of nonspecific symptoms of psychological distress, such as worry. At the level of primary health care, there is a strong tendency among physicians to regard patients who repeatedly consult without a sufficient underlying physical illness as legitimate users of their services, and to view these consultations as primarily psychological in nature. Nonetheless, there remains an unexplored category of consultation in which the patient is primarily concerned about physical symptoms that do not, in themselves, warrant such a level of concern. The concept of health anxiety has been coined as part of a proposed model of the process underlying repeated consultations of this sort. Health anxiety is defined as “concern about health in the absence of pathology or excessive concern when there is some degree of pathology” [1]. In Warwick and Salkovskis’s formulation, high levels of health anxiety lead to repeated actions aimed at improving health or ruling out the presence of disease [2]. Persons with high levels of health anxiety may consult multiple practitioners and take multiple remedies. Reassurance-seeking behavior is negatively reinforced the by short-term reduction in anxiety, which it provides. The development of a scale to measure health anxiety allows the empirical testing of this model. We administered the Health Anxiety Questionnaire [1] to general practice attenders under the hypothesis that higher levels of health anxiety would be associated with a greater frequency of visiting, and especially of self-initiated visiting, as well as differences in both patient and doctor perception of the visit.

Two hundred general practice attenders were interviewed, of whom 56 were men (23%). The median age was 31 years (25th percentile=25, 75th percentile=44). Data regarding age on completion of education were available for 172 subjects (the remainder were still in education). Median age of completion of education was 18 (25th percentile=16, 75th percentile=21). The number of previous visits in the 12 months before interview ranged from 0 to 56. The median number of visits was 3.5, with a median of 3 self-initiated visits. When the total health anxiety score was scaled using the same response metric as the original items, running from 0 (none) to 3 (most of the time), the mean health anxiety score was 0.5 (median 0.4); 25% of subjects scored at or below 0.2, and 75% at or below 0.7. The average difference between successive deciles was 0.1—in other words, an increase of 0.1 in health anxiety score corresponds to a shift of one decile upward. The Health Anxiety Questionnaire had a reliability of 0.845 (Cronbach’s α). There was no significant difference between men and women, but there was a modest decrease in health anxiety with age. Scores fell 0.04 for every 10-year increase in age (t=−2.581, p=0.011). Robust linear regression was used to evaluate the relationship between health anxiety score and number of visits, corrected for age and gender. Both health anxiety and number of visits were square-root transformed. There was a borderline association between health anxiety score and total visits (t=1.8, p=0.067). This corresponds to a predicted mean level of visits of 3.3 per year in the lowest decile of the Health Anxiety Questionnaire scores, against a mean of 4.6 in the highest decile. Self-initiated visits were significantly associated with health anxiety, corrected for age and gender (t=2.1, p=0.033). This corresponds to a predicted mean of 2.6 visits a year in the lowest decile of health anxiety and 4.2 in the highest, corrected for age and gender. There were 84 attenders (42%) who had asked someone for advice about the problem for which they were consulting the doctor (63 of these—75%—had asked a friend). Those who had asked someone for advice had a mean health anxiety score of 0.55, whereas the 116 who had not sought advice had a mean score of 0.45. This difference was statistically significant (tested on square-root-transformed scores, t=−2.68, p=0.008). Age and gender were also related to advice-seeking: men were less likely to seek advice than women (odds ratio=0.49, z=−1.987, p=0.047) and older people less likely to seek advice than younger (odds ratio for a 10-year increase in age=0.63, z=−3.7, p<0.001). Corrected for these findings, the odds of seeking advice increased by 1.13 (13%) for each decile increase in health anxiety (z=2.124, p=0.034). The predicted odds of seeking advice rose from 0.25 in the lowest decile of health anxiety to 0.56 in the highest decile. Sixty-five people (32.5%) believed that the doctor might have to refer their problem to a specialist. They had a mean health anxiety score of 0.58, against those who believed that no referral would be necessary, whose mean score was 0.45. Using logistic regression to correct for age and gender, the odds of believing that the GP might have to refer an individual’s problem to a specialist rose by 16% (odds ratio 1.16, z=2.63, p=0.008) for each decile increase in health anxiety score. The predicted odds of a patient believing that the doctor would have to refer them rose from 0.22 in the lowest decile of health anxiety to 0.48 in the highest decile. In fact, 21 patients were actually referred to a specialist, and they did not differ significantly in their level of health anxiety from those who were not referred. Only 38 people (19%) believed that they would not need a prescription, and their mean health anxiety score (0.46) was very similar to the mean of those who thought they might need a prescription (0.50). Logistic regression confirmed that there was no relationship between decile of health anxiety score and believing that one would not need a prescription (odds ratio=0.98, z=−0.250, p=0.802). Likewise, there was no association between level of health anxiety and actually receiving a prescription. A total of 155 patients received prescriptions (77.5%). The doctors were asked to rate the importance of the prescription on a scale that ran from “serious medical consequences if the patient does not take the prescription” to “likely that the patient’s problem may run the same course whether or not they take the prescription.” There were 31 prescriptions (20%) classified under the latter heading. The mean health anxiety score of those who received prescriptions that may have been superfluous was 0.46, against a mean of 0.51 in those who did not. The odds of receiving a superfluous prescription were unaffected by decile of health anxiety score (odds ratio=1.08, z=0.680, p=0.496). Of the 162 patients who had thought they would need a prescription, 28 (17.3%) did not obtain one. These patients had a mean health anxiety score of 0.42, against a mean of 0.51 in those who correctly thought they would require a prescription. There was no association between deciles of health anxiety score and the odds of the patient mistakenly believing they would get a prescription (odds ratio=0.90, z=−1.320, p=0.187). There were 170 people who stated that they expected to feel reassured by a consultation with their doctor. Their mean health anxiety score was 0.48, against a mean of 0.53 in those who did not expect to feel reassured. Once again, logistic regression revealed no significant impact of deciles of health anxiety score on the odds of being reassured (odds ratio=0.98, z=−0.212, p=0.832). Older patients, however, were more likely to state that they expected to be reassured after visiting the doctor, with a 50% increase in the odds of being reassured for every 10-year rise in age (odds ratio=1.51, z=2.302, p=0.021). One hundred seventy-nine people stated that they were usually reassured by a visit to the doctor. Their mean health anxiety score was 0.47, against 0.60 for those who did not usually find visits to the doctor reassuring. Logistic regression confirmed that there was a slight decrease in the odds of being reassured (odds ratio=0.89, corrected for age and gender), but this was not significant (z=−1.3, p=0.196). Of the 200 patients, 34 had been previously referred for investigation of symptoms that had not resulted in any medical diagnosis. Their mean health anxiety score was 0.50, against a mean of 0.49 for those who had never been thus referred. Logistic regression showed that there was essentially no relationship between deciles of health anxiety score and the odds of having a negative investigation of symptoms following referral (odds ratio=0.99, z=−0.138, p=0.890).