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Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms. An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collaboration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.

Evidence has suggested that cognitive-behavioral therapy (CBT) is effective in reducing hypochondriacal symptoms, and another line of evidence has suggested that CBT is also effective in reducing pain and the psychological conditions associated with chronic low-back pain (CLBP). The purpose of this study was to examine the effectiveness of CBT among hypochondriacal patients with and without CLBP.

Somatizing patients have maladaptive and increased rates of medical care utilization. If there were a way of routinely identifying such patients, one that did not require intensive, case-by-case review, they could be targeted for specific interventions to improve their use of medical care.

Somatosensory amplification refers to a tendency to experience somatic and visceral sensations as unusually intense, noxious, and disturbing. The authors wanted to determine whether somatosensory amplification is a stable construct or whether it might change with antidepressant therapy. Fifteen patients with fibromyalgia and 17 patients with major depressive disorder received antidepressant treatment and were assessed after 6 and 12 weeks of treatment. Amplification scores responded to antidepressant treatment in patients with major depression but not in patients with fibromyalgia, despite a decrease in the levels of depression in both groups. When change in depression and anxiety scores was partialled out from change in somatosensory amplification scores, the amplification scores did not change significantly in either the depressed or the fibromyalgia groups. Given the small numbers and the marginal significance of the results, the authors are unable to say definitely just how independent of depression somatosensory amplification is. Whether somatosensory amplification is a measure of depression per se should be tested in a more definitive and larger future study.

To examine the relationship between somatosensory amplification and three factors of alexithymia (difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking), 48 outpatients attending a Japanese psychosomatic clinic and 33 comparative outpatients completed the Somatosensory Amplification Scale (SSAS), 20-item Toronto Alexithymia Scale (TAS-20), Profile of Mood States (POMS), and other self-rating questionnaires. The scores on the SSAS and the first and second TAS-20 factors were higher (all P < 0.001) in the psychosomatic group than in the comparison group. The SSAS was positively associated (both P < 0.01) with these two TAS-20 factors, controlling for the effects of age, sex, group, and POMS tension-anxiety and depression. Somatosensory amplification appears to be associated with difficulties identifying and describing feelings, not externally oriented thinking, in Japanese patients.

To examine the resource utilization of patients with high levels of somatization and health-related anxiety.

Somatization mechanisms are poorly understood. The authors tested whether somatization might involve altered central nervous system information processing. They measured somatization using the Somatization Sensation Inventory (SSI) and information processing style using the Hyperarousal Scale, scores of which correlate with electroencephalogram(EEG) measures of cortical electrical responsiveness. SSI scores correlated highly with Hyperarousal scores. On logistic regression, two SSI items and two Hyperarousal items accounted for most of this correlation. These specific hyperarousal items had previously been found to covary with EEG activity and cortical evoked potential amplitudes. The authors concluded that somatization may involve altered CNS processing of somatic stimuli.

Background:This study examined the effect of anxiety on symptom reduction through a behavioral medicine intervention in a Mind/Body Medicine Clinic. Method:Participants were 1,312 outpatients attending a 10-week behavioral medicine intervention which included training in the relaxation response, cognitive restructuring, exercise and nutrition. All of the patients had physical symptoms and were referred to the clinic by their physician. The Medical Symptom Checklist (12 major symptoms), Symptom Checklist 90 Revised (SCL-90R), Stress Perception Scale and the Health-Promoting Lifestyle Profile were administered before and after the program. Results:Of the sample, 1,012 patients completed the program, and 911 completed the posttreatment assessment. Self-reported frequency of medical symptoms, degree of discomfort and interference with daily activities were significantly reduced as a result of the program. Anxiety and other psychological distress as measured by the SCL-90R and stress perception scales also showed significant reductions. Furthermore, health-promoting lifestyle functioning significantly improved. High levels of pretreatment anxiety predicted a decrease in the total number of medical symptoms endorsed. Conclusions:Behavioral medicine interventions are effective in reducing medical symptoms coinciding with improvement in anxiety. High anxiety at program entry may predict better outcome.

In two studies, the authors evaluated the impact of psychiatric disorders on medical care utilization in a primary care setting. In the first study, 526 consecutive patients in a teaching hospital primary care practice completed the 18-item RAND Mental Health Inventory to identify clinically significant depression and/or anxiety and a questionnaire about the use of psychiatric treatment and psychoactive medications. The medical utilization of those patients defined as depressed and/or anxious was compared with those defined as not depressed and/or anxious. Patients identified as depressed and/or anxious reported significantly increased medical utilization, but this was not confirmed by the hospital's computerized record system. In the second study, the authors analyzed medical care utilization for the years before and after the first outpatient psychiatry appointment of a sample of 91 patients referred from the same primary care practice to the hospital's outpatient psychiatry clinic over a 1-year period. In both studies there was not a statistically significant difference in medical utilization among those patients receiving psychiatric treatment. The findings demonstrate the difficulties in examining cost offset in a primary care population and raise questions about it as a realistic outcome measure of the effect of psychiatric treatment.

The conceptualization of somatization and what were previously termed somatoform disorders has changed substantially in the DSM-5 compared with previous diagnostic systems. The current diagnostic criteria for somatic symptom disorder (SSD) require the presence of symptoms (Criterion A) combined with a substantial impact of these symptoms on thoughts, emotions, and behaviors (Criterion B). In this issue of Psychosomatic Medicine, Toussaint et al. describe the development and empirical validation of a self-report questionnaire —the SSD-12— to assess the new psychological criteria (the “B criteria”) of DSM-5 SSD. This is an important contribution because previously there was no questionnaire available to assess the B Criterion of SSD. The new DSM-5 criteria for SSD no longer require the absence of an adequate medical explanation for a somatic symptom, but rather define positive diagnostic criteria, focusing on the psychological impact of the somatic symptoms rather than their purported (medical) cause. Although this new conceptualization of somatization-related disorders has several advantages, seriously ill medical patients may well score high on the B Criterion for SSD on that basis alone and not because their psychological response to the medical illness is disproportionate or excessive. Measures of medical morbidity therefore need to be included in the interpretation of the SSD in individuals with severe medical conditions. Given the revised DSM-5 criteria, the newly developed and validated SSD-12 is a useful tool for diagnosing and monitoring treatment response in SSD.

• Consecutive visitors to a general medicine outpatient clinic were screened with a hypochondriasis questionnaire. Two-thirds (n = 41) of those exceeding a preestablished cutoff met the criteria for DSM-III-R hypochondriasis when given a structured diagnostic interview, while the other third (n = 22) did not. The latter group showed significant decreases in their hypochondriasis questionnaire scores over a 3-week interval. They had less psychiatric disorder and more medical morbidity than the DSM-III-R hypochondriacs. They also viewed their medical care more positively, and their physicians considered them less hypochondriacal. The transiently hypochondriacal group was also compared with a random sample (n = 75) of the patients below the cutoff on the screening instrument. They had more Axis I disorder, more personality disorder, reported higher levels of somatosensory amplification, and more medical disorder. The differences in psychiatric comorbidity and amplification persist when medical morbidity is controlled for by matching and analysis of covariance. This is consistent with the hypotheses that among patients confronted with a medical illness, those with personality disorder and those who are sensitive to somatic sensation are more likely to develop transient hypochondriasis.

• We attempted to integrate the DSM-III criteria for hypochondriasis with the clinical literature and derived six positive and two negative diagnostic criteria. Seven of these were assessed in a random sample of 92 medical outpatients by means of a self-report questionnaire, structured interview, and medical record audit. The results are in accord with previous work: there appears to be considerable internal validity and consistency in the syndrome in that disease conviction, disease fear, bodily preoccupation, and somatic symptoms are significantly intercorrelated. The three hypochondriacal attitudes (conviction, fear, and preoccupation) were not statistically related to the number of medical diagnoses in the patients' medical records. Depressive symptoms, as measured by the Beck Depression Inventory, were highly correlated with the other hypochondriacal symptoms. The hypochondriacal syndrome in these patients appears to be consistent with the clinical disorder described in DSM-III.

Forty-one Diagnostic and Statistical Manual of Mental Disor ders-Ill-Revised hypochondriacs were accrued from a primary care practice. Seventy-five control subjects were selected at random from among the remainder of the patients in the same clinic. All subjects completed a structured diagnostic interview and standardized self-report questionnaires. Medical morbidity was assessed with a medical record audit and with primary physicians' ratings. The hypochondriacal and comparison sam ples did not differ in aggregate medical morbidity, although the hypochondriacal sample had more undiagnosed complaints and nonspecific findings in their medical records. Within the compar ison sample, higher levels of medical morbidity were associated with higher levels of hypochondriacal symptoms. This occurred primarily because the most serious medical disorders were as sociated with more bodily preoccupation, disease conviction, and somatization. Within the hypochondriacal sample, no corre lation was found between the degree of hypochondriasis and the extent of medical morbidity.(Arch Intern Med. 1991;151:84-88)

We developed a structured diagnostic interview for DSM-III-R hypochondriasis (SDIH) that is the first such clinician-administered instrument. The SDIH was administered to 88 general medical outpatients who scored above a predetermined cutoff on a hypochondriacal symptom questionnaire, and to 100 comparison patients randomly chosen from among those below the cutoff. Using the joint assessment method, interrater agreement on the DSM-III-R diagnostic criteria was 88 to 97 and agreement on the diagnosis was 96. Concurrent validity was suggested by a significant correlation between the interview and the primary care physicians' ratings of hypochondriasis. A measure of external validity was demonstrated in that several clinical characteristics thought to be ancillary features of hypochondriasis were significantly more prevalent in interview-positive patients than in interview-negative patients. Finally, the SDIH appeared to have discriminant validity in that patients diagnosed as hypochondriacal had several other clinical features that distinguished them from the patients who scored above the cutoff on hypochondriacal symptomatology, but failed to be diagnosed as hypochondriacal with the SDIH.

The goal of the study was to examine the functional status and medical care of general medical outpatients with panic disorder. One hundred patients completed self-report questionnaires and a diagnostic interview for panic disorder. They were compared with a random sample of patients without panic disorder. Medical morbidity was assessed from the medical record, and the patients’ clinic physicians completed a questionnaire about them. The prevalence of current (1 month) panic disorder was 6.7%–8.3%. The panic disorder patients had fewer serious medical diagnoses, but more medical utilization and more role impairment than the comparison group. The clinic physicians rated the panic patients as more anxious, more depressed, more hypochondriacal, and more difficult to care for. Sixty-one percent of the panic disorder patients recalled receiving an anxiety disorder diagnosis. These findings add to a growing body of evidence that panic disorder imposes a significant burden on those with this illness and that it is a seriously underdiagnosed condition in primary care practice.

• The "nonspecific" and nonpharmacologic aspects of taking medication are important in several clinical situations: when patients insist on a medicine that is not clinically indicated; when they refuse an appropriate medication; when they are repeatedly troubled by side effects from a variety of drugs; and when they do not adhere to the regimen. The patient's behavior in these situations may be motivated by the psychological meanings, interpersonal communications, or social consequences of taking pills. The physician may be able to identify these psychosocial factors by learning about the patient's prior experiences with medications, by eliciting his views of physicians and medical care, and by understanding the consequences of becoming a patient.(Arch Intern Med 1983;143:1544-1548)

Forty-one DSM-III-R hypochondriacs were obtained by screening consecutive visitors to a general medical clinic and compared with 76 patients randomly chosen from the same setting. They completed a research battery consisting of a structured diagnostic interview (DIS) and self-report questionnaires to measure hypochondriacal symptoms and functional impairment. The criterion standard for diagnosing hypochondriasis was a structured interview of demonstrated reliability and validity. The six-month prevalence of DSM-III-R hypochondriasis was estimated to be between 4.2% and 6.3% of consecutive attenders who met the inclusion criterion of having visited the same physician before. This rate was somewhat lower than that found for generalized anxiety disorder and comparable to that of alcohol abuse. The hypochondriacal patients did not differ significantly from the comparison random sample in sociodemographic risk factors except that they were significantly more likely to be Black. Hypochondriacal symptomatology was similar in males and females; and in those over 65 and those under 65. Over a three-week interval, hypochondriacal symptoms remained stable, and hypochondriacal patients had significantly higher levels of long-term disability than did the comparison patients.

Ninety-two general medical outpatients were surveyed with an interview, questionnaires, and a medical record review to investigate the relationships among psychiatric disorder (depression and hypochondriasis), somatic symptoms, medical morbidity, and the utilization of ambulatory medical services. Medical utilization correlated with the number of somatic symptoms reported (r 0.49, P 0.0001), depressive symptoms (r 0.34, P 0.001), and the number of medical diagnoses in the medical record. Somatic symptoms were not significantly correlated with the number of medical diagnoses, but were related to hypochondriacal attitudes (r 0.52, P 0.0001) and depression (r 0.51, P 0.0001). In stepwise multiple regressions, the number of medical diagnoses accounted for 33 of the variance in medical utilization. Somatic symptoms were the second most powerful predictor, increasing R2to 0.469. The next best predictors were two hypochondriacal attitudes and the presence of a major psychiatric diagnosis in the medical record. This five-step model explained 56 of the variance. Somatic symptoms are thus powerful determinants of medical utilization, even after controlling for medical morbidity. Depression, disease fear, and bodily preoccupation are also important predictors of utilization. Somatic symptoms are a final common pathway through which emotional disturbance, psychiatric disorder, and organ pathology all express themselves, and which prompt patients to visit doctors.

• The current ambulatory training of medical residents in the primary care program and the traditional program of the Massachusetts General Hospital, Boston, are described. All residents are assigned to work in a single medical group practice unit during their three years of training. Block outpatient rotations make up 32% of the primary care program and 6% of the traditional program schedules, while total ambulatory experiences, including weekly continuity sessions, make up 39% and 15% respectively. Several components are important for a successful program. Above all is a vigorous group practice providing a sizable panel of patients with complex clinical problems from which residents can learn. Also important are financial support from the hospital and government or private grants and a commitment to outpatient teaching by the medical and nonmedical specialty staff.(Arch Intern Med 1986;146:1805-1809)

• Any given pathological lesion produces somatic symptoms whose Intensity varies widely among different patients, and In the same patient at different times. There is clinical and experimental evidence that a patient's level of symptomatic distress is amplified by four factors as follows: the thoughts he has about his symptom, the degree to which he pays attention to it, his mood, and the situational context. These factors can be used therapeutically in maximizing palliation and symptomatic relief for patients with chronic medical diseases. Discussing the causes of the patient's symptoms can be helpful, as can strategies to maximize distraction and focus the patient's attention away from his body. Aggressive treatment of anxiety and depression is indicated in chronically symptomatic patients, and behavioral interventions to alter the family's response to the patient's symptoms can also be palliative.(Arch Intern Med 1986;146:905-909)

Self-administered screening questionnaires are available to assist primary care physicians in detecting undiagnosed depression and anxiety disorders. This study used receiver operating characteristic (ROC) analysis to evaluate three such tests the General Health Questionnaire (GHQ), the Mental Health Inventory (MHI), and the Somatic Symptom Inventory (SSI). Stratified by the results of a preliminary GHQ, 364 health maintenance organization (HMO) members were given these tests and a Diagnostic Interview Schedule (DIS), the latter used as a “truth” standard for current psychiatric diagnosis. The MHI performed significantly better than the GHQ in detecting mental disorders generally and anxiety disorders in particular, and somewhat better in detecting affective disorders. The SSI performed best in detecting anxiety disorders and was significantly better than the GHQ. When subjects who had participated in a previous study involving repeated GHQ administration were excluded, sensitivity of all tests improved, especially the GHQ. We conclude that the MHI can be a useful tool for screening primary care patients, and that the SSI has additional predictive value with respect to anxiety disorders.

We compared the screening accuracy of a short, five-item version of the Mental Health Inventory (MHI-5) with that of the 18-item MHI, the 30-item version of the General Health Questionnaire (GHQ-30), and a 28-item Somatic Symptom Inventory (SSI-28). Subjects were newly enrolled members of a health maintenance organization (HMO), and the criterion diagnoses were those found through use of the Diagnostic Interview Schedule (DIS) in a stratified sample of respondents to an initial, mailed GHQ. To compare questionnaires, we used receiver operating characteristic analysis, comparing areas under curves through the method of Hanley and McNeil. The MHI-5 was as good as the MHI-18 and the GHQ-30, and better than the SSI-28, for detecting most significant DIS disorders, including major depression, affective disorders generally, and anxiety disorders. Areas under curve for the MHI-5 ranged from 0.739 (for anxiety disorders) to 0.892 (for major depression). Single items from the MHI also performed well. In this population, short screening questionnaires, and even single items, may detect the majority of people with DIS disorders while incurring acceptably low false-positive rates. Perhaps such extremely short questionnaires could more commonly reach use in actual practice than the longer versions have so far, permitting earlier assessment and more appropriate treatment of psychiatrically troubled patients in primary care settings.

Receiver operating characteristic (ROC) analysis was used to evaluate the usefulness of three self-administered screening instruments in helping primary care physicians detect anxiety and depressive disorders. This research was secondary to an investigation of hypochondriasis. The three tests were the Whitely Index (WI), the Somatosensory Amplification Scale (SAS), and the Somatic Symptom Inventory (SSI). Participating subjects were 75 patients seen in a general medical clinic and diagnosed as being free of hypochondriasis by DSM-III-R criteria. Psychiatric disorder was assessed with the Diagnostic Interview Schedule, version III-A. The three instruments delineated patients with depressive disorders versus no depressive disorders and patients with anxiety disorders versus no anxiety disorders. For depressive disorder, the areas under the curve (AUC) were 0.87, 0.75, and 0.82 for the WI, SAS, and SSI, respectively. For anxiety disorders the AUCs were 0.79, 0.76, and 0.74, respectively, for the three tests. Although the WI yielded slightly higher values, the areas under the ROC curves did not differ significantly among the three tests. Because of its relatively short length —13 items—it was concluded that the WI can be useful for screening primary care patients, both with respect to depressive and anxiety disorders.

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 selfreport 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&lt;.001), somatized less (P&lt;.05), were less disabled (P&lt;.001), were more satisfied with their medical care (P&lt;.001), and were rated by their physicians as less help rejecting (P&lt;.05) and less demanding (P&lt;.01). Major depression was more prevalent in the group with panic disorder (66.7% vs 45.1%; P&lt;.05), as were phobias (76.0% vs 37.3%; P&lt;.001), but somatization disorder symptoms (P&lt;.0001) and generalized anxiety disorder were less prevalent (74.5% vs 16.0%; P&lt;.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.

• Forty-two DSM-III-R hypochondriacs from a general medical clinic were compared with a random sample of 76 outpatients from the same setting. Patients completed a research battery that included a structured diagnostic interview (Diagnostic Interview Schedule) and self-report questionnaires to measure personality disorder caseness, functional impairment, and hypochondriacal symptoms. Psychiatric morbidity in the hypochondriacal sample significantly exceeded that of the comparison sample. Hypochondriacs had twice as many lifetime Axis I diagnoses, twice as many Diagnostic Interview Schedule symptoms, and three times the level of personality disorder caseness as the comparison group. Of the hypochondriacal sample, 88% had one or more additional Axis I disorders, the overlap being greatest with depressive and anxiety disorders. One fifth of the hypochondriacs had somatization disorder, but the two conditions appeared to be phenomenologically distinct. Hypochondriacal patients with coexisting anxiety and/or depressive disorder (secondary hypochondriasis) did not differ greatly from hypochondriacal patients without these comorbid conditions (primary hypochondriasis). Because the nature of hypochondriasis remains unclear and requires further study, we suggest that its nosologic status not be altered in DSM-IV.

Patient noncompliance with medical regimens is one of the major unsolved therapeutic problems confronting the medical profession today. Physicians have great difficulty identifying and dealing with noncompliers. A critical review of the literature has disclosed that the factors most consistently related to noncompliance are (1) psychological factors, (2) environmental and social factors, (3) characteristics of the therapeutic regimen, and (4) properties of the physician-patient interaction. Based on this information, a strategy for the improved diagnosis and management of noncompliance is feasible.(JAMA 228:1563-1567, 1974)

Medical technology is having major effects on health care decision making at the patient-physician interaction, community-health care institution, and society-national government levels. This impact is characterized by three processes—diffusion of decision making through the increase of possible alternatives, the relinquishing of part of the role of decision maker to others in the health care system, and the shift of some of the decision making process onto the object (patient or community) of that decision. These processes are having their most pronounced effect at the national government level where decisions regarding the allocation of limited societal resources are often made without sufficient weight being given to the intended or negative consequences of specific technologies or to their external and opportunity costs, since these may not be the concern of powerfully organized special interest groups. We recommend that if national decision making is to represent societal choices, mechanisms such as technological review panels and public notification forms, must be established for ferreting out relevant social, economic and ethical considerations early in the development of a technology and disclosing these to the public.

This study describes a 2-part approach to the hypochondriacal patient: 1) a strategy for medical management, and 2) a specific psychiatric therapy. Medical management rests on the physician's recognition that patients have psychological and interpersonal reasons for feeling symptomatic and seeking medical attention. After gaining this appreciation, the physician can stop trying to cure the patient's symptoms, and the goal of management then shifts to assisting the patient in coping with the symptoms. A specific psychotherapy is then presented. Group discussions and cognitive and behavioral exercises are used to teach patients to moderate four factors that amplify somatic distress and hypochondriacal health concerns: the attention they pay to their symptoms, their thoughts about them, the context in which they experience their symptoms, and their moods.

Renormalization arguments are developed and applied to independent nearest-neighbor percolation on various subsets ℕ of ℤd,d≧2, yielding:Equality of the critical densities,pc(ℕ), for ℕ a half-space, quarter-space, etc., and (ford>2) equality with the limit of slab critical densities.Continuity of the phase transition for the half-space, quarter-space, etc.; i.e., vanishing of the percolation probability,θℕ(p), atp=pc(ℕ).

Reviewing the literature of the latter half of the twentieth century, the authors consider the question: do women somatize more than men? The literature review begins with work done in the 1950s in order to look at the phenomenon of somatization as a constellation of symptoms. It encompasses work done in the general community and in the medical arena. The critique of the literature shows why the role of gender in somatizing remains unclear, elucidates inconsistencies, notes the confounding variables, and points out the degree of variable interaction and observer bias. Possible explanations or causes of gender differences are explored. In the present body of literature, women do somatize more than men; however, some of the studies in the literature are flawed. The changing gender difference in medical literature implies that the inquiry at hand concerns the etiology and expression of somatization itself.

This study examined the decisions patients made about obtaining follow-up care after an initial visit to a psychiatric walk-in clinic. Sixty-nine randomly selected patients who received a variety of ambulatory referrals were questioned by means of structured and unstructured interviews. Sixty-seven per cent of them visited the facility they were referred to, and 70 per cent of the patients given medication took it substantially as prescribed. Completion of the referral was associated with being employed, not abusing drugs and alcohol, having a positive view of the walk-in clinic, and adherence to the medication regimen. Referral success was unrelated to sociodemographic characteristics, social integration, the nature of the intended disposition, or prior medical or psychiatric care. Patients who adhered to the disposition did not necessarily adhere to the medication regimen, and vice versa. Referrals were more successful when the patient had preceded the clinical encounter with an active appraisal of his situation. The decision to adhere was a complex and prolonged one in which the patient weighed many factors, of which the physician's suggested disposition was only one.

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.

The authors studied the relative contributions of psychological characteristics and rheumatoid arthritis (RA) morbidity to RA symptoms and medication side effects. Thirty-one consecutive patients attending an RA clinic completed self-report questionnaires and diaries assessing RA symptoms and somatic style, a constellation of beliefs, attitudes, and concerns about disease and health. After 3 months, the patients were assessed for RA symptoms and self-reported medication side effects. At inception, RA symptoms were associated with several components of somatic style. At 3-month follow-up, changes in RA symptoms and the incidence of medication side effects were predicted by somatic style variables measured at inception. The symptoms of RA and the side effects of RA pharmacotherapy are prospectively predicted by somatic style as well as by the severity and extent of RA.

For a family of translation-invariant, ferromagnetic, one-component spin systems—which includes Ising and ?4 models—we prove that (i) the phase transition is sharp in the sense that at zero magnetic field the high- and low-temperature phases extend up to a common critical point, and (ii) the critical exponent ß obeys the mean field bound ß?1/2. The present derivation of these nonperturbative statements is not restricted to “regular” systems, and is based on a new differential inequality whose Ising model version isM?ßh?+M3+ ßM2?M/?ß. The significance of the inequality was recognized in a recent work on related problems for percolation models, while the inequality itself is related to previous results, by a number of authors, on ferromagnetic and percolation models.