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The Loin Pain and Haematuria Syndrome is a relatively new diagnosis applied to the problem of persistent loin pain, often with haematuria, in the absence of identifiable explanatory organic pathology. Case reports have suggested a range of salient psychopathological features associated with the complaints of pain and haematuria, although the psychological factors have been largely neglected in understanding the aetiology or in approaches to management. The roles of illness behaviour, patterns of somatisation, and psychiatric disorder associated with chronic pain syndromes, need to be addressed, as do the patterns of medical and surgical response to these patients. The use of the term “syndrome” to describe these symptoms implies a degree of uniformity in clinical features and outcome that has not yet been substantiated. New surgical techniques have been developed such as renal denervation and renal auto-transplantation to treat the pain, with limited success. A review of this condition illustrates the frequent failure of medicine to apply multi-factorial biopsychosocial models to understanding the aetiology and management of unexplained physical symptoms. It also illustrates the failure of our current nosology and understanding of somatoform disorders to achieve application outside psychiatry.

The Illness Behaviour Questionnaire (IBQ) (Pilowsky and Spence 1983) was administered to 824 pain clinic patients over a 10-year period. Their responses to this 62-item self-report questionnaire were analysed using a numerical taxonomy programme. Of the 6 valid classes generated, 2 classes were delineated by at least 5 unique items. The main difference between these 2 classes, revealed by the item responses, was the acceptance or rejection of a psychological viewpoint. Comparison on the basis of mean IBQ scale scores indicated that, while members of both classes maintained the presence of a somatic disorder, they differed not only in their report of psychological symptoms but also by whether they showed an awareness of life problems unrelated to their physical problems.

The discussion of health and illness is basic to any consideration of the experience of ageing. In this chapter we examine the objective and subjective aspects of physical health and disability. The chapter concludes with a discussion of the psychological dimensions of ageing.

This is a study of the illness behaviour of 100 Chinese psychiatric patients referred consecutively to the psychiatric unit of a general hospital in Singapore. More women than men felt that their illness was due to spirit possession; but belief in possession was not related to educational status. Thirty-six patients or their relatives had consulted a traditional healer before going to the hospital. Duration of illness, sex and educational status were not associated with the tendency to seek help from the traditional healer; there was also no significant difference between psychotic or neurotic patients. The majority of depressed patients (72%) presented with somatic complaints of chest discomfort, headache and abdominal discomfort. Somatization was not related to the educational level or sex of the patients.

In view of the variable and unpredictable efficacy and toxicity of non-steroidal anti-inflammatory and disease-modifying anti-rheumatic drugs, it is not surprising that some patients with rheumatoid arthritis elect to cope without recourse to these medications. We describe four of these patients, consider the lessons to be learnt, and identify further research that needs to be done on this aspect of illness behaviour.

A principal component analysis was carried out on the 62-item Illness Behaviour Questionnaire responses of 832 pain clinics and patients and 746 psychiatric in-patients in the same general hospital. Analyses were carried out for the groups separately, and combined ( N = 1578). The factors obtained were compared to those of the original study, Pilowsky and Spence J Psychosom Res 1975, 19: 279–287, and studies by Zonderman et al. Hlth Psychol 1985; 4: 425–436, and Main and Waddell Pain 1987; 28: 13–26. Varying degrees of robustness of the original factors was demonstrated and this is discussed in relation to the clinical context in which the IBQ is used. The significance of five new factors which emerged is discussed. They were labelled ‘Interpersonal Sensitivity’, ‘Responsiveness to Medical Reassurance’, ‘Illness Impact’, ‘Self Appraisal’ and ‘Biological Functions’.

The irritable bowel syndrome (IBS) is characterized by alimentary and non-alimentary symptoms; the aim of this study was to assess the clinical value and discriminant function of non-alimentary symptoms in the irritable bowel syndrome. Alimentary and non-alimentary symptoms, estimated daily dietary fibre intakes, ability to express personal feeling, anxiety and depression ratings, and life events and difficulties inventories were compared in 128 hospital out-patients with IBS and 113 age and sex matched control subjects not seeking health care, randomly recruited from the community. Alimentary symptoms correlated closely with those non-alimentary symptoms often associated with the hyperventilation syndromes, difficulties in expressing personal feelings and anxiety, and depression ratings. Life events and difficulties, and estimated daily dietary fibre intakes did not differ significantly between patients and controls. With the exception of abdominal bloating, no significant gender differences were observed in IBS symptoms in either the IBS or control groups. The irritable bowel syndrome is one facet of a more general condition of illness behaviour which includes the hyperventilation syndrome and an inassertiveness in expressing personal feelings. Though non-alimentary symptoms did not improve diagnostic accuracy beyond that achieved by a combination of alimentary symptoms, their recognition provides alternative approaches to the management of refractory IBS.

Patients with new or worsening chest pain suggesting acute coronary syndromes need treating as an emergency. Rapid assessment is crucial but difficult. Patients with acute chest pain now represent 20% or 30% of all emergency medical admissions, yet less than one third of these will have acute coronary syndromes (acute myocardial infarction or unstable angina).1 The majority thus do not have significant coronary heart disease. There are approximately 600 000 unnecessary admissions each year in the UK. If adequately investigated, on the basis of rule out algorithms, admission could be avoided. However, up to 2% of acute myocardial infarctions are mistakenly sent home with perhaps a 25% case fatality rate and a high risk of medicolegal problems.2–4 Any effective scheme would potentially save substantial NHS resources and reduce stress for patients, carers and staff.1 It is important to emphasise the social context. This is a continuous spectrum ranging from patients who never present grading imperceptibly into patients who present as emergencies. The trigger for such presentation represents the final step in a complex pathway commencing with the patient's perception of symptoms, illness behaviour, family and social norms, advice from significant others, level of education, availability of primary care support, access to accident and emergency (A&E) and response of A&E staff. Although the incidence of coronary heart disease …

This case report offers a different perspective on a patient with a long-term non-psychotic psychiatric disorder that was difficult to specify. The patient, a man in his 50s, was unable to profit from outpatient treatment and became increasingly dependent on mental healthcare – which could not be understood based on his history and psychiatric symptoms alone. By separating symptoms from illness behaviour, the negative course of this patient9s treatment is analysed. Focusing on ineffective chronic illness behaviour by the patient, and mutual ineffective treatment behaviour by the clinicians, it becomes clear that basic requirements of effective treatment were unmet. By making a proper diagnosis, clarifying expectations and offering a suitable therapy, ineffective illness behaviour was diminished and this ‘difficult’ case became much easier for both patient and clinicians. The illness behaviour framework offers a useful, systematic tool to analyse difficulties between patients and clinicians beyond psychiatric symptoms or explanations.

Chronic Fatigue Syndrome (CFS) often presents with severe subjective symptoms and may be accompanied by severe global impairment. No specific treatment has yet been proven to be universally effective; CBT and graded exercise has so far lead to moderately positive results. We present a treatment model based on a comprehensive, educational, cognitive-oriented and mindfulnes-based intervention program, where illness perception and illness behaviour are being challenged. Knowledge of the illness, a comprehensible illness model and understanding unexplainable symptoms constitute the education program. Mindfulness training and stress reduction, combined with cognitive group therapy are essential part of the program. Knowledge, thoughts and feelings are being adressed, including the experience of life satisfaction and positive and negative emotions.We present data on stress parameters, mindfulness items and lifte satisfaction factors, pre and post treatment.

Complex illness behaviour can be seen as a product of dysfunctional communication between doctors and patients. A methodology to understand such behaviour is described: it uses case record analysis and meetings with patients and health teams to create a set of family trees and graphs of consultation patterns; these are the basis on which to generate and test hypotheses. This model is used to explore the consultation rates of a family between the 1940s and 1988. Illness behaviours increased rapidly during the 1980s at a time when both the family and their general practitioners were undergoing rapid changes and losing significant members. Mutually unacknowledged depression may have been a key factor. Strategies for change are suggested.

A 5 yr follow up of Irritable Bowel Syndrome (IBS) is described. With the notable exception of abdominal pain, gastrointestinal symptoms changed little over this period, and were unrelated to the overall improvement in wellbeing reported by 65% of patients. The anxiety ratings of the improved and unimproved groups at initial assessment and 5 yr later are considered. There was a persisting trend towards higher ratings in those who did not improve, and an exaggeration of this trend after 5 yr, which owed more to a reduction in anxiety in those who improved than to an increase in the anxiety ratings of those who did not. There was no evidence that depression ratings behaved similarly. We suggest that anxiety may be more important in the maintenance of the IBS symptom complex, and depression more important in determining intercurrent fluctuations in perceived distress and illness behaviour in response to adverse life events.

Observation of overt pain behaviours was carried out by physicians during routine clinical examination of 120 patients with chronic low back pain. Reliable ratings were achieved but only after very careful standardization in an additional 60 pilot patients. Overt pain behaviour was found to be related to other clinical measures of illness behaviour—pain drawing, behavioural symptoms, behavioural signs, use of walking aides and downtime—but did tap an additional dimension. It is concluded that clinical observation of overt pain behaviour can provide useful additional information about illness behaviour in low back pain. Reliable observations can be achieved in a carefully standardized research situation but in routine clinical practice are vulnerable to considerable observer error and bias.

Questions concerning the respondents' actions in response to hypothetical illnesses have been used in a number of studies of illness behaviour and health service utilization, but the answers obtained have never been validated by direct comparison with the respondents' behaviour during episodes of real illness. Five hundred and fifty-four questionnaires were returned by parents giving details of how they would respond to hypothetical episodes of cough, fever and sore throat in their children. During a two-month period of recording, the children suffered 78 episodes of one or other of these symptoms which led to a consultation. The aim of this study was to compare the parents' responses to the hypothetical situations in the questionnaire with what they said they had done before each of these consultations for real illness. The comparison concentrated on the intervals that parents waited before requesting consultations, and on their medication of their children. The parents' responses to the questionnaire were poor predictors of their reported behaviour during actual illness episodes.

One hundred and thirty-three female patients admitted to a neurological ward were fully investigated for the presence of organic neurological disease, and assessed for psychiatric disorder and illness behaviour, using the Clinical Interview Schedule (CIS) and the Illness Behaviour Questionnaire (IBQ). The likelihood of the presenting symptoms being due to organic disease was expressed by the neurologists on a visual analoque scale and the psychiatrists used a similar technique to describe whether the symptoms could be the result of psychiatric disorder. Many patients either had clear organic disease or somatic presentation of psychiatric disorder ‘somatization’, but one-third fell between these two extremes and either had a complex mixture of the two types of illness or could not be accurately diagnosed. The IBQ scores were raised in those with psychiatric disorder but did not help to explain why some patients present to the neurologists with symptoms that are unexplained by either organic disease or psychiatric disorder. Close liaison between neurologists and psychiatrists increases the detection of psychiatric disorder but some patients would require long-term follow-up to understand the true nature of the underlying disorder.

Invention, production or falsification of physical and psychological symptoms, are the core traits of Factitious Disorder. The aim is to assume a patient role.The etiology of Factitious Disorder is unknown, but cognitive-behavioural and psychoanalytic hypothesis have been formulated.Cognitive-Behavioural theories consider that the Factitious Disorder is related to the learning of illness behaviour with its positive and negative reinforcements. Therefore, past medical history in childhood or medical illness in relatives are risk factors for the development for Factitious Disorder.A Case-Control study was carried out to test this hypothesis. Patients with the diagnosis of Factitious Disorder with Psychological symptoms in a Psychiatric Inpatients Unit were included. We analyze medical history in childhood, age at the first admission in hospital, consequences derived of the patient role during this admission, and age and consequences of the first somatic and psychiatric severe episode in adult age.Data obtained in our study show that patients with Factitious Disorder with psychological symptoms have a higher proportion of illness in childhood and higher percentage of admissions. In addition, hospital admissions take place in the late childhood, when is possible to be conscious of the consequences of the illness.These results confirm that learning influences the pathogenesis of Factitious Disorder with psychological symptoms.

EDITOR,--Over the past few years I have seen a growing number of patients with the chronic fatigue syndrome who have been told by psychiatrists and psychologists that abnormal illness behaviour and psychosocial factors are the main factors perpetuating their disability. Few patients have accepted or believed this explanation; neither have I. The ME Association now has evidence that the fashionable theory …

A new measure of depressiveness in speech content and the Schedule of Recent Experiences are used to predict illness reports and clinic use in two samples of subjects. The results suggest that the more life change the subjects reported, the more depressiveness they verbalized, and that both life change and depressiveness scores predict illness reports and health service users. Multivariate combinations of the measures of life change and depressiveness gave better predictions than either measure alone, and the measure of depressiveness for the most part gave somewhat better predictions than the life change measure. This suggests that it is important to quantify reactions to life events. In addition, it suggests that the two longstanding currents of interest in psychosomatic medicine which concern the importance of life events on the one hand and of affective and intrapsychic events on the other can profitably be integrated.

Management of intractable facial pain is often referred to a specialised Pain Relieving Clinic, especially in light of the evidence that psychological factors play a part in the maintenance of the pain. A group of 60 patients so referred were divided into two groups according to diagnosis. The 32 diagnosed as suffering from trigeminal neuralgia were found to be more likely to deny non-pain problems, less irritable, but less convinced that there was a physical disease process responsible for their pain, than the 28 patients with non-neuralgic facial pain. Personality factors did not discriminate between the two groups. The relevance of the difference between these two groups to our understanding of pain is discussed, as is the special place of pain in the face.

The present paper reviews some of the major fields of interest in current life event research. Some theoretical issues are examined: for example, generality versus specificity of life event effects, the time span encompassed by life event research, development of life change scales, and perceptual concensus concerning the severity of life changes. Methodological problems concerned with causal or correlational conclusions and illness behaviour are also discussed. Models of the life event stress process are mentioned with reference to ‘resistance resources’. Finally the field of life event research has been integrated into McGrath’s conceptualization of stress research.

The utilization of general hospitals in Finland in 1974 was studied according to occupational groups. The material was based on two registers; the register of hospital utilization kept by the National Board of Health and the register for the Population and Housing Census prepared by the Central Statistical Office in Finland. The differences in hospital utilization do not depend only on differences in morbidity; hospital utilization is also associated with the availability of services and with the illness behaviour of the people--factors which also differ from occupational group to occupational group. The utilization of hospital services was quantified by recording the number of patients discharged from hospitals. The highest age-standardized utilization by males was found in industry (186/1000 population), being 1.6 times greater than in administration, 1.4 times greater than in agriculture, 1.3 times greater than in transport and services and 1.1 times greater than in sales. The greatest utilization by females was found in sales (262/1000 population and in industry (239/1000 population), being 1.3 times greater in sales than in administration. Differences between occupational groups were generally smaller than among males. The utilization of hospital services was compared with mortality in these occupational groups. There is a rather strong positive correlation (r = 0.7) between hospital utilization and mortality in males. In agriculture the utilization was lower than average in comparison with mortality. In administration and industry the utilization was at the same level as mortality.

The term ‘conversion’ implies a correlation between conversion symptoms, hysteria, and hysterical personality. A clinical case of conversion related to chronic post-traumatic disorder, with paranoid features, was successfully treated by anti-psychotic drugs; it illustrates the non-specific nature of conversion symptoms. Mechanic's concept of ‘illness behaviour’ is a frame-work that meets the need for a broader understanding of conversion symptoms.

A 34 item self-administered questionnaire designed to measure aspects of illness behaviour was completed by 30 patients undergoing long-term haemodialysis. A principal components analysis of the data yielded 8 factors (together accounting for 75% of the total variance) which were subjected to orthogonal rotation. The patterns of factor loadings suggested meaningful dimensions which were labelled: ‘helpless dependence’, ‘distressing preoccupation’, ‘openness vs concealment’, ‘paranoid non-involvement vs optimistic involvement’, ‘surrender vs fight’, ‘paranoid hostility to the illness as an enemy’, ‘illness as a non-attributable challenge’ and ‘lack of information about illness’. A comparison was made with an earlier study on a smaller group of patients and this revealed some encouraging similarities in the patterns of illness behaviour.

Patients attending a sexually transmitted diseases (STD) clinic were asked to complete the General Health Questionnaire and the Illness Behaviour Questionnaire. Data were collected from 852 patients. One-third of the sample were found to score positively on the GHQ, indicating possible psychological disturbance. Women were more likely than men to score positively on the GHQ. On the General Hypochondriasis scale of the IBQ the sample's scores were higher than any other normative data except those obtained from psychiatric in-patients. On this scale homosexual and bisexual males scored significantly higher than heterosexual males. It is argued that the IBQ draws attention to important dimensions of psychological distress in STD clinics.

The BMA report fails to understand medicine both in relationship to society and in an historical context. The concept of disease reflected in the document belongs to a limited scientific model which characterizes constellations of physical symptoms and the biological conditions which underlie them, and ignores social factors, psychological correlates and illness behaviour

Substantial differences are shown to exist between marital groups in their mortality rates, illness experience and use of health services. Evidence is presented which suggests that only a small part of the observed variations can be attributed to the selective effects of marriage and remarriage. The main factor appears to be that of the effects of the occupancy of different marital states, with this being associated with differences in stress, life styles and social support, as well with possible differences in illness behaviour and what is perceived as their relative needs for care from the official services.

The illness behaviour of Qutari psychiatric patients is defined by the nature of their symptomatology. The importance of somatic symptoms is determining the patient role and patient-doctor relationship is discussed in the light of cultural characteristics of the Qutari community. Delusory cultural beliefs related to possession, sorcery and envy provide a conceptual framework of explanation of many disorders. Inter-generational conflict is an important factor in neurotic disorders. Failure to report symptoms in an abstract fashion is characteristic of Qatari patients. The cultural and religious heritage absorbs many behaviours which would otherwise be considered symptomatic of psychiatric disorder.