Family Practice Advance Access originally published online on May 16, 2005
Family Practice 2005 22(4):406-411; doi:10.1093/fampra/cmi038
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The worried young adult as a primary care patient
a Primary Health Care Centre, PL 42, FIN-30101 Forssa, b Department of Teacher Education, FIN-20014 University of Turku, c Department of Statistics, FIN-20014 University of Turku, d Centre for Cognitive Neuroscience, FIN-20014 University of Turku and e Department of Psychiatry, University of Helsinki, Finland
Correspondence to Virpi Laakso, Pihatie 12, FIN-31300 Tammela, Finland; Email: virpi.laakso{at}utu.fi
Received 28 April 2004; Accepted 1 April 2005.
Laakso V, Niemi PM, Grönroos M, Aalto S and Karlsson H. The worried young adult as a primary care patient. Family Practice 2005; 22: 406–411.
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Abstract |
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Background. Being worried about one's complaint is common among primary health care patients. Persistent and intensive worry may, however, have negative consequences.
Objectives. We explored complaint-related worry and factors associated with it among 18- to 39-year-old primary health care patients.
Methods. Sixty-two patients evaluated the intensity of their worry and the severity of their complaint before seeing their GP. They were also interviewed about their background and filled in questionnaires about general tendency to illness-related worry and psychiatric symptoms.
Results. The intensity of worry varied greatly. One fourth of the patients reported intense worry. A general tendency to worry about health and hostile reactions were associated with both the intensity of worry and the severity appraisals. The patient's education and the duration and perceived course of the complaint also played a role in worrying and in the perceptions of the severity of the complaint.
Conclusions. Some psychological characteristics may dispose patients to intensive worrying and pessimistic appraisals of their complaint. This challenges the GP to pay attention to the patients' perspectives and knowledge. Careful elucidation of the patients' experiences of their complaints is especially indicated in the case of complaints of long duration and a stable course.
Keywords. Primary health care, worry, young adult patients.
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Introduction |
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Primary care patients are commonly worried about their symptoms and the underlying causes. Previous studies indicate that about two-thirds of the patients intending to see their GP have a problem-related worry in mind, including the fear that their somatic symptom might be a sign of a serious illness.1
Worry about a complaint can be considered a normal human reaction to a health threat and adaptive in motivating the patient to seek medical help.2 Persistent, intensive worry, however, may lead to excessive use of health care services,3 dissatisfaction with care4 and poor recovery.5
Patients usually do not spontaneously disclose their worries to their doctors.6 It would therefore be useful for the GP to be aware of the factors commonly associated with a low or high level of worry. That would also make them alert for patients needing special attention for their concerns.
Earlier studies have shown that a high degree of complaint-related worry is associated with some complaint characteristics, such as the type4 and duration7 of the complaint. Additionally, factors associated with the patient's own evaluations, such as a low self-rated health status, suspicion that the complaint is serious7 and uncertainty about the nature of the problem1 also play a role in worrying. Furthermore, the patients' life experiences and medical knowledge as well as their previous predisposition to illnesses and their medical management probably affect their interpretations of their bodily sensations and consequent emotional reactions, such as health anxiety.8
So far, the development of long-term illness-related worry is not well known. Previous studies1,4,7 have mostly dealt with adults from various age groups, including elderly people, who often already have diagnoses of chronic or serious illnesses. The present study is a part of a larger study on the development of long-term illness worry and somatisation. We focused on primary care patients in early adulthood and middle age with somatic complaints other than common cold to capture patients in the early stages of worrying. With this focus, we were able to study the subjective worry of patients with probably short illness histories and complaints whose origin would not be obvious to the patient.
The aim of this study was to explore patients' ratings of the intensity of their complaint-related worry and the severity of their current complaint and, additionally, to assess factors predicting these evaluations.
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Methods |
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The study was carried out in a public primary health care centre with a family doctor system, serving the 38 000 inhabitants of the town of Forssa and its rural surroundings in southern Finland. As a general rule, the patients only need to wait a very short time for an appointment. For example, a patient calling for an appointment in the morning may be scheduled for a consultation during the same day.
Receptionists asked 18- to 39-year old patients with somatic complaints other than common cold to participate. When the patients called the health care centre, they usually said what their complaint was. The receptionist could consult the electronic appointment scheduling system to see if it was a control visit. The receptionists could thus exclude the patients who did not meet the inclusion criteria.
After informed consent, the researcher (psychologist) asked the patients to arrive for a study interview half an hour before the scheduled consultation with a GP. The present study is a part of a larger study exploring the change processes in worry and the development of long-term worry in young adults. For this reason, the patients were asked to arrange time for also being interviewed after the consultation. This time-consuming interview protocol and the short waiting time for the appointment occasionally led to a situation where a patient was unable to make the necessary arrangements for participation.
The patients were informed that the interview by the researcher was additional to the health services provided by the health centre and would not affect the care they would receive. In addition, the confidentiality of the study was emphasised. The doctors in the health care centre were generally informed about the ongoing study, but it was only after the consultation that they were informed which of their patients belonged to the sample. The patients were distributed between the 16 doctors working in the health care centre.
In a semi-structured interview, the patients were asked about the type, duration and perceived course of their complaint and about the stressfulness of their life. They also evaluated the intensity of their subjective worry about their complaint and its severity (both based on their assumption that it would be treated and based on their assumption that it would go untreated) on visual analogue scales (VAS 0–100, for worry: 0 = not at all worried, 100 = extremely worried; for severity: 0 = not at all serious, 100 = life-threatening).
At the end of the interview, the patients completed the Illness Worry Scale (IWS)9 and the Symptom Check-List-90 (SCL-90).10 The IWS (range 0–9) measures the tendency to worry about being or becoming ill, the sensitivity to pain and the tendency to think that other people do not take one's illness seriously enough. The SCL-90 measures symptom reporting on nine psychiatric sub-scales (range 0.00–4.00).
Afterwards, each patient's doctor evaluated the medical severity of the patient's complaint by classifying it into one of the following categories: self-limiting (probably harmless and self-limiting illness or dysfunction of the body, for instance, muscle tension), curable (there is causal treatment available for the illness, but it is not seriously threatening the patient's life or functioning even if left untreated, for instance, otitis media), chronic (chronic condition, whose symptoms can be alleviated, but whose cause cannot be cured, and this condition is not seriously threatening the patient's life or functioning, for instance, allergic eczema), treatment-requiring (seriously threatening the patient's life or functioning if not treated, for instance, tonsillitis) or severe (seriously threatening the patient's life or functioning even if treated, for instance, cancer, diabetes).
The notes in the patient charts at the health care centre are usually very scarce and, as such, uninformative to another doctor not familiar with the patient and his/her health and overall life situation. Therefore, it was appropriate to have the classification made by only the family doctor. The use of double-checking by another doctor would not have remarkably enhanced the reliability of the classification.
Statistical analyses
The difference between the severity ratings of the complaint assumed treated and assumed untreated was analysed by Student's t-test for paired samples. The associations between the intensity of worry and the severity ratings were analysed by Spearman's rank correlation coefficient (rs). The statistical significance of the quantitative and categorical variables associated with the intensity of worry and the severity ratings was analysed with regression analysis and analysis of variance. Only the ratings concerning complaint severity assumed treated were analysed, because they reflect the patient's experience of a health threat more appositely at the moment when he or she is about to get medical attention for the complaint. All significant variables were used at the second stage of the analysis. General linear model (GLM) is a convenient, simple generalisation of regression and variance analysis to handle both quantitative and categorical independent variables that may interact. General linear models were fitted with significant variables and the doctor-evaluated severity of the complaint to find the significance and to detect the interactions of these variables. Non-significant terms were dropped from the model one by one. Finally, the partial correlation of the intensity of worry and the severity ratings assumed treated was computed. The statistical package of the SPSS version 11.0 for Windows was used.
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Results |
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Of the 127 patients approached, 107 were eligible and 45 (42%) were not able to participate, mostly (32 patients, 71%) due to practical problems and the need to make arrangements at very short notice (e.g. absence from work, transportation). Two patients were too sick to participate, eight patients did not want to participate, and three patients did not give any reason for their refusal. The refusers did not differ statistically significantly from the participants in terms of sex or age (Table 1).
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The mean age of the participants (n = 62) was 27 years (SD = 5.7 years). The duration of the complaints varied from a few hours to ten years, the median being 26 days (M = 238 days, SD = 592 days). Other personal background and complaint characteristics are presented in Table 2.
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The vast majority of patients (n = 55, 89%) scored below the cut-off of 4 points for hypochondriacal worry on the IWS.9 The mean of the IWS sum scores was 1.4 (SD = 1.8). The internal consistency of the Finnish version in this sample was good (Cronbach's alpha.74).
The mean values of the different sub-scales of the SCL-90 ranged from 0.21 (SD = 0.37) for phobic anxiety to 0.85 (SD = 0.48) for somatization and 0.84 (SD = 0.75) for depression, which correspond to the scores of the non-psychiatric community population in Finland.11
Two thirds of the patients' complaints were classified by the GPs as self-limiting or curable; none were classified as severe (Table 2). The medical severity of the complaint was associated neither with the intensity of complaint-related worry (F-value = 0.846, P = 0.475) nor with the patients' evaluations of the severity of their complaint (severity assumed untreated: F-value = 0.963, P = 0.416; severity assumed treated: F-value = 1.966, P = 0.129).
Intensity of worry and its risk factors
There was marked variability in the patients' ratings of the intensity of their complaint-related worry (M = 59.7, SD = 30). It is worth noticing that 23% scored over 90 and 65% over 50 points on the visual analogue scale.
GLM-based analysis showed that vocational education, the IWS sum score, the SCL-90 hostility and phobic anxiety scores and the duration of the complaint were associated with the intensity of the patients' worry (Table 3). In other words, more intense worry was experienced by the patients whose complaint had lasted for at least two weeks, who had no vocational education, and who scored higher on illness-related worry and hostility, but lower on phobic anxiety. No interactions between the risk factors were found. This model explained 36% of the variance in the intensity of worry.
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Ratings of the severity of the complaint and their associations with worry
The severity ratings of the complaints assumed untreated (range = 5–100, M = 46.8, SD = 24.4) were almost symmetrically distributed, whereas the distribution of the severity ratings of the complaints assumed treated (range = 0–74, M = 13.8, SD = 16.5) was strongly positively skewed. The difference in means between these two severity ratings was statistically significant (t = 9.92, df = 61, P < 0.001), which means that the patients rated their complaint as less severe when they considered it to have been treated.
Both severity ratings correlated significantly with the intensity of worry (rs for severity assumed untreated 0.440, P = 0.001 and for severity assumed treated 0.293, P = 0.021). In other words, the more severe the patients rated their complaint, the more worried they were about it.
The severity ratings of the complaint and the risk factors associated with it
The SCL-90 hostility sub-scale score, the IWS sum score and the perceived course of the complaint were significantly associated with the severity rating of the complaint. The general linear model also revealed a two-variable interaction between the course of the complaint and the IWS sum score (Fig. 1). The IWS sum score had a positive association with the severity rating, but only for the patients who had rated their complaint as stable. In other words, the complaints were rated as more severe by the patients who scored high on illness worry and on hostility and whose complaint had troubled them constantly since its emergence (Table 4). This model explained 42% of the variance in the severity ratings.
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The partial correlation of the intensity of worry and the severity ratings (assumed treated), when all the significant risk factors (duration and course of the complaint, vocational education, IWS sum score and the SCL-90 sub-scales for phobic anxiety and hostility) had been controlled for, was.1408, which was not statistically significant (P = 0.301). Hence, these factors also explain the association between the intensity of worry and the severity rating.
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Discussion |
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Our study indicates that primary care patients in young adulthood may feel extremely worried about their complaints, even ones not likely to be due to a serious illness. The intensity of worry is not directly associated with the medical severity of the complaint. Instead, subjective worry is predicted by the patient's psychological characteristics and education as well as his/her perception of the duration and course of the complaint.
More than 80% of the patients in our sample were 18–32 years old. They contacted the primary care centre with various complaints that are fairly common in the general population12 and in the primary care settings.13 Most often, the patients suffered from musculoskeletal symptoms and headache, and their complaint had usually lasted for less than 3 months. The majority of patients were non-hypochondriacal,9 and their reports of psychiatric symptoms were accordant with the SCL-90 scores of the Finnish non-psychiatric population.11
The intensity of complaint-related worry varied greatly among the patients. It is noteworthy that a fairly large proportion—i.e. one fourth—of them reported intense worry. This proportion is approximately the same as the estimated prevalence of somatisation in primary care.14 Our finding on a close association between the intensity of worry and the perceived severity of the complaint is in accordance with the observations by Van de Kar et al.7 and the ideas of Salkovskis8; the perceived awfulness of illness is one crucial factor underlying health anxiety. Usually, the patients regarded their complaints as clearly less severe when they assumed them treated compared to non-treated. This obviously indicates their trust in health care services and also suggests that the degree of health anxiety depends on the perceived rescue factors, such as the available treatment.8
Contradictory to what could be expected, the intensity of the patients' worry was not associated with the medical severity of the complaint. In other words, in cases of young adults with non-serious complaints, the GP cannot automatically predict the patient's worry on the basis of his/her own medically based evaluation of the complaint's severity. It is possible that different findings might have been obtained if the sample had included patients with severe illnesses.
It turned out that the patients whose complaints had lasted for more than two weeks were more worried. Furthermore, if the complaint had bothered the patient in a similar way since its emergence, she/he tended to perceive it as more severe, even if assumed treated. Kroenke and Jackson also demonstrated that the patients whose complaints had not improved within 2 weeks were more likely to report persistent illness-related worry in 3-month follow-up.5 Further research is warranted on the relative and combined impacts of different complaint characteristics, including the duration, course and type of the complaint, on worrying.
The association between the intensity of worry and the appraisals of complaint severity disappeared when we controlled all the risk factors. It is probable that complaint-related worry and severity appraisal are basically two manifestations of the same complaint-related experience of imminent threat, the former reflecting its emotional and the latter its cognitive dimension, as proposed in the parallel processing model by Leventhal et al.15
Patients with a general tendency to worry about health were more prone to feel extremely worried about their current complaint and to evaluate a constantly bothering complaint as severe even if assumed treated. Similarly, the tendency to hostile reactions predicted a higher level of worry and higher ratings of severity. These dispositions have some resemblance to negative affectivity16—e.g. worry, hostility and interpersonal problems—which is often found to be related to frequent symptom reporting, health anxiety and somatisation.17,18 This suggests that these patients need special attention from the GP because they may develop the most threatening attributions for their complaints. Inquiries about the patient's perceptions of the duration and course of the complaint may serve as an easy start for the doctor to approach the patient's ideas and worry concerning the cause and severity of the complaint. In this way, the GP could gradually proceed in addressing the patient's possibly erroneous thoughts about complaints, which may otherwise remain hidden.
Further research is needed on the impact of consultation and the doctor–patient relation on possible changes in patients' worrying and perceptions of their complaints. It would be important to know if the worry persists or if the patients get relieved—or perhaps become even more worried during the consultation—and what factors predict these changes.
One methodological limitation of this study is the fairly high (42%) refusal rate, which was mainly due to the demanding research procedure and practical problems in participation. The refusal rate is, however, comparable to that (49%) reported by Robbins and Kirmayer in an interview study in primary care.9 The refusers did not differ from the participants in view of age and sex. Although it is unlikely that the refusers would have significantly biased the sample, we cannot exclude the possibility that the patients who were more concerned about their complaints might have been more willing to discuss health-related matters with an interviewer. Such bias would mean an overrepresentation of intense worry in this study.
Our sample was small and we did not have normative data on illness worry in Finnish population. Consequently, any conclusions on the present findings should be made with caution, and further research on larger samples is needed to test them.
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Declaration |
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Funding: this study was supported by grants from Finnish Cultural Foundation, from Signe and Ane Gyllenberg's Foundation and from the Hospital District of Kanta-Häme and the Health Care District of Forssa (EVO budgets).
Ethical approval: the study protocol was approved by the ethical committee of the Central Hospital District of Kanta-Häme.
Conflict of interest: none.
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1 Southgate LJ, Bass MJ. Determination of worries and expectations of family practice patients. J Fam Pract 1983; 16: 339–344.[ISI][Medline]
2 Fink P, Ewald H, Jensen J et al. Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization. J Psychosom Res 1999; 46: 261–273.[CrossRef][ISI][Medline]
3 Connelly JE, Philbrick JT, Smith GR Jr, Kaiser DL, Wymer A. Health perceptions of primary care patients and the influence on health care utilization. Med Care 1989; 27[Suppl 3]: 99–109.
4 Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas ChA. Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions and 2-week outcome. Arch Int Med 1997; 157: 1482–1488.[Abstract]
5 Kroenke K, Jackson JL. Outcome in general medical patients presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up. Fam Pract 1998; 15: 398–403.
6 Barry ChA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. Br Med J 2000; 320:1246–1250.
7 Van de Kar A, Van der Grinten R, Meertens R, Knottnerus A, Kok G. Worry: A particular determinant of consultation illuminated. Fam Pract 1992; 9: 67–75.
8 Salkovskis PM. The cognitive approach to anxiety: threat beliefs, safety-seeking behavior and the special case of health anxiety and obsessions. In Salkovskis PM (ed.), Frontiers of cognitive therapy. New York: The Guilford University Press; 1996, 48–74.
9 Robbins JM, Kirmayer LJ. Transient and persistent hypochondriacal worry in primary care. Psychol Med 1996; 26: 575–589.[ISI][Medline]
10 Derogatis LR, Lipman RS, Covi L. SCL-90: An outpatient psychiatric rating scale—preliminary report. Psychopharm Bull 1973; 9: 13–28.[Medline]
11 Holi MM, Sammallahti PR, Aalberg VA. A Finnish validation study of the SCL-90. Acta Psychiatrica Scand 1998; 97: 42–46.[ISI][Medline]
12 Tibblin G, Bengtsson C, Furunes B, Lapidus L. Symptoms by age and sex. The population studies of men and women in Gothenburg, Sweden. Scand J Prim Health Care 1990; 8: 9–17.[Medline]
13 Njalsson T, Mcauley RG. Reasons for contact in family practice. Scand J Prim Health Care 1992; 10: 250–256.[Medline]
14 Gureje O, Simon GE, Üstün TB, Goldberg DP. Somatization in cross-cultural perspective: a World Health Organisation study in primary care. Am J Psychiatry 1997; 154: 989–995.[Abstract]
15 Leventhal H, Benyamini Y, Brownlee S et al. Illness representations: theoretical foundations. In Petrie KJ, Weinman JA (eds), Perceptions of health and illness. Current research and applications. Singapore: Harwood academic publishers; 1997, 19–45.
16 McClure EB, Lilienfeld SO. Personality traits and health anxiety. In Asmundsson GJG, Taylor S, Cox BJ (eds), Health Anxiety. Clinical and research perspectives on hypochondriasis and related conditions. Chichester: Wiley; 2001, 65–91.
17 Kirmayer LM, Robbins JM, Paris J. Somatoform disorders: personality and the social matrix of somatic distress. J Abnorm Psychol 1994; 103: 125–136.[CrossRef][ISI][Medline]
18 Wetzel RD, Guze SB, Cloninger CR, Martin RL, Clayton PJ. Briquet's syndrome (hysteria) is both a somatoform and a "psychoform’ illness: a Minnesota Multiphasic Personality Inventory Study. Psychosom Med 1994; 56: 564–569.
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