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Psychiatry 73(1) Spring 2010

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Hypochondriacal Symptoms Associated With a Less Therapeutic Physician-Patient Relationship


Russell Noyes, Jr., Susan L. Longley, Douglas R. Langbehn, Scott P. Stuart, and Oladipo A. Kukoyi

The purpose of this study was to examine the association between hypochondriacal symptoms and the physician-patient relationship. Family medicine patients (w = 310) completed self-report measures of hypochondriacal symptoms, quality of physician-patient relationship, and variables likely to influence that relationship. These variables included physician relationship factors, such as duration of relationship and frequency of visits, as well as patient characteristics, such as neuroticism and positive and negative affectivity. Hypochondriacal symptoms were negatively correlated {r = -.24) with the quality of physician-patient relationship. In addition to hypochondriacal symptoms, the regression model included having a primary physician, length of relationship with that physician, frequency of physician visits, and the level of positive affectivity in the patient. Hypochondriacal symptoms appear to be associated with a less therapeutic physician-patient relationship. Physicians must recognize symptoms of this kind in order to properly address the relationship needs of their patients. Hypochondriasis or health anxiety is a preoccupation with the fear of having, or the belief that one has, a serious disease despite evidence to the contrary. So defined, the disorder affects between 2 and 7 percent of patients attending primary care clinics and is a cause of physical dysfunction and disability (American Psychiatric Association, 1994). It is also a reason for increased health care utilization and dissatisfaction with care received. Disorders such as hypochondriasis may influence the relationship that develops between patient and physician, and that relationship may in turn affect the outcome of care, including patient reassurance or lack thereof. According to the interpersonal model of hypochondriasis, fear of disease and somatic symptoms are expressions of distress aimed at eliciting reassurance from others, especially primary care physicians (Balint, 1972; Henderson, 1974). The disorder develops in those with insecure attachment or relationship styles resulting from childhood exposure to inadequate parenting (Stuart 6c Noyes, 1999). The person with such a style forms a lasting image of him- or herself as unworthy of care and/or of others as unwill-

Russell Noyes, MD, Douglas R. Langbehn, MD, PhD, and Scott P. Stuart, MD are affiliated with the Department of Psychiatry, College of Medicine, College of Public Health at the University of Iowa in Iowa City. Douglas Langbehn is also with the Department of Biostatistics there. Susan L. Longley, PhD is with the Department of Psychology, Illinois Institute of Technology in Chicago, Illinois. Oladipo A. Kukoyi, MD is with the Department of Psychiatry and Behavioral Science at the University of California Davis in Sacramento. Address correspondence to Russell Noyes, MD, Psychiatry Research, Medical Education Bldg., Iowa City, IA 52242-1000; e-mail: russell-noyes@uiowa.edu

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ing or unable to provide it (Bowlby, 1975; Griffin & Bartholomew, 1994). Early experience with illness (in oneself or one's family) increases the likelihood that distress will manifest somatically. Evidence for this model of hypochondriasis is beginning to accumulate (Ciechanowski. Walker, Katon, & Russo, 2002; Waldinger, Schulz, Barsky, & Ahern, 2006). For instance. Noyes, Stuart, Langbehn, Happel, Longley, Mller, and Yagla (2003) observed a relationship between hypochondriacal symptoms and insecure attachment styles among primary care outpatients. In their sample, such symptoms were positively correlated with all the insecure styles, especially the fearful style. They were also positively correlated with interpersonal problems but negatively correlated with reassurance from medical care. Wearden, Perryman, and Ward (2006) found that those with a preoccupied attachment style (15%) had significantly higher hypochondriasis scores than those with other styles. In the general population, Schmidt, Straus, and Braehler (2002) found hypochondriacal features and multiple physical symptoms in anxiously attached individuals. Persons with insecure attachment, such as those with hypochondriasis, tend to have relationships that are problematic and unsatisfactory (Bartholomew, 1997; Noyes, Stuart et al., 2003). Evidence for this comes from physicians who find such patients demanding yet rejecting of help that is offered (Brown & Vaillant, 1981). They typically describe hypochondriacal patients as having unsubstantiated complaints and as both difficult and ungrateful (Barsky, Wyshak, &c Klerman, 1991; Schwenk, Marquez, Lefever, & Cohen, 1989; Hahn, Thompson, Wills, Stern, & Budner, 1994). On the other hand, hypochondriacal patients describe their physicians as uncaring and indifferent to their distress (Lin, Katon, Von Korff, Bush, Lipscomb, Russo, & Wagner, 1991; Persing, Stuart, Noyes, & Happel, 2000; Peters, Stanley, Rose, &c Salmon, 1998). To them, physicians seem unwilling or unable to solve their

health problems. Many patients report negative encounters during which their symptoms are challenged and requests for help denied. Yet, the key to treatment of hypochondriacal patients is this very patient-physician relationship. According to Starcevic (1991), medical reassurance is possible when a therapeutic relationship exists. Under such circumstances, the patient's mistrust may give way, and he or she may feel accepted, even nurtured, by the physician. Indeed, what the hypochondriacal patient appears to seek is not so much removal of symptoms as the acceptance and concern of the doctor (Adler, 1981; Barsky, Wyshak, & Klerman, 1991). What is currently lacking is empirical evidence of such patient-physician interaction. The aim of this study is to examine the association between hypochondriacal symptoms and the physician-physician relationship in a primary care clinic. For this purpose, we developed a measure of the therapeutic relationship. We hypothesized that hypochondriacal symptoms would be associated with a less therapeutic relationship after other factors infiuencing that relationship had been taken into account. METHODS Subjects This study was approved by the University of Iowa, College of Medicine's review board. Patients from the University of Iowa, Family Care Center were approached as they arrived for appointments by an investigator (SLL) who described the study and obtained written consent. Those agreeing to participate were given questionnaires and asked to complete and return them in the addressed envelope provided. Patients age 18 to 65, who received most of their care at the center, were included. Excluded were patients with serious medical or psychiatric conditions or those who were unable to complete ques-

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Hypochondriacal and somatic symptoms. The Illness Attitude Scales (IAS) is a measure of hypochondriacal symptoms or health anxiety (Kellner, Abbott, Pathak, Winslow, & Umland, 1983). It consists of 27 items that assess worry about illness, concerns about pain, hypochondriacal beliefs, thanatophobia, disease phobia, bodily preoccupations, treatment experience, effects of symptoms, and health habits. They are rated on fiveMeasures point linear scales (0 = not at all to 4 = almost always). Studies examining the factor strucQuality of physician-patient relationship. ture of the IAS have identified two factors: The perceived quality of the physician-patient hypochondriacal symptoms (health anxiety) relationship was assessed by the Physician- and functional impairment (illness behavior) Patient Relationship Scale (PPRS) (Table 1). (Speckens, Spinhoven, Sloekers, Bolk, &c van The PPRS was developed to measure rela- Hemert, 1996; Speckens, 2001). tionship quality in the primary care setting. Somatic symptoms were assessed usItems for the scale were obtained from the ing the Somatic Symptom Inventory (SSI) literature dealing with therapeutic relation(Barsky, Cleary et al., 1992). This measure ships and with empathy, affective bond, colconsists of 26 items from the MMPI hypolaboration, and so forth, important elements chondriasis scale and the Symptom Checkin such relationships (Balint, 1972; Frank, list - 90 somatization scale. Responses are 1991; Horvath, Gaston, & Luborsky, 1993; obtained on five-point linear scales (1 = not Horvath & Symonds, 1991; Jackson, 1999; at all to 5 = extremely). Scores on the SSI Martin, Garske, & Davis, 2000; Seigler &c are strongly correlated with those for hypoOsmond, 1974). Existing scales that focus chondriacal symptoms (Barsky, Wyshak, & on aspects of therapeutic relationships (e.g., Klerman, 1986). trust, reassurance, satisfaction, alliance) were also reviewed for possible items (Anderson Patient dispositional variables. Neuroticism & Dedrick, 1990; Hojat, 2007; Horvath & was measured using the Big Five Inventory Greenberg, 1989; Safran et al., 1998; Saun(BFI) neuroticism scale (John & Srivastava, ders, Howard, & Orlinsky, 1989; Speckens, 1999). The BFI contains 44 items to assess

tionnaires. A majority of those who accepted questionnaires returned them (65%). A total of 310 subjects returned questionnaires. These included 230 (74%) women and 80 men with a median age of 36 years. Those who returned the questionnaires differed significantly with respect to age (38 years vs. 35 years) and sex (67% women vs. 54% men) from those who did not. They had a median 16 years of education and $20,000 to $40,000 annual household income. Subjects included 48% who were married, 36% single, and 16% divorced or widowed. With respect to health problems, 29% reported they were not at all serious, 43% not very, 23% moderately, and 8% very or extremely serious. Most were white (94%). A majority (74%) reported having a primary doctor, defined as one "who handles most of your medical care and you regard as your personal physician." This doctor had provided care for a median of one year. Patients reported a median of four physician visits in the past year.

Spinhoven, van Hemert & Bolk, 2000). Responses were obtained using five-point linear scales (1 = not at all to 5 = extremely). The following instructions were given: "What follows is a list of questions about the relationship you have with your doctor. Please indicate your answer by circling the appropriate number to the right of each one. Your doctor will not see or have access to your response." Initial testing was done to remove redundant or ambiguous items. Remaining items covered the areas of affective bond and commitment, mutual respect and collaboration, reassurance, effective communication, knowledge and skills, and integrity.

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TABLE 1. The Physician-Patient Relationship Scale Showing Factor Loadings for Individual Items Loading 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. How well does your doctor understand the concerns you have? How committed is your doctor to your well-being? How completely does your doctor accept you? How genuine is your doctor? How carefully does your doctor listen to you? How much do you trust your doctor? How knowledgeable is your doctor? How much support or encouragement does your doctor give you? How much help does your doctor give you in dealing with health problems? If you were to become seriously ill, how confident are you that your doctor would do everything possible? How determined is your doctor when dealing with serious health problems? How seriously does your doctor take your health problems? If you were in pain or were suffering, how sensitive wouid your doctor be? How completely does your doctor understand your health problems? If you were not feeling well, how sympathetic would your doctor be? How well does your doctor explain health problems or treatments to you? How respectful is your doctor of you? How important does your doctor consider your opinions to be? How reassuring is your doctor? How thorough is your doctor in examining you? How skilled is your doctor in his or her area of practice? How much does your doctor care about you as a person? How adequate is your doctor's explanation of your symptoms? How comfortable is your doctor when examining you? How freely can you speak to your doctor about personal matters? How hopeful is your doctor about the outcome of your health care? How certain are you that your doctor will be there when you need him or her? How possible is it that your doctor has overlooked something? .90 .90 .90 .90 .89 .87 .87 .87 .86 .86 .85 .85 .83 .83 .82 .82 .82 .81 .80 .80 .80 .79 .78 .77 .77 .73 .70 .58

the five major dimensions of personality. Items are rated on five-point scales of agreement (1 = very unlike me to 5 = very like me). The 8-item neuroticism subscale is strongly correlated with the neuroticism scale of the NEO Personality Inventory, the standard for measurement in this area (Costa &c McCrae, 1992). Positive and negative affectivity were measured using the Positive and Negative Affect Schedule (PANAS) (Watson, Clark, & Tellegen, 1988; Watson, Wiese, Vaidya, & Tellegen, 1999). Positive affectivity is the tendency to experience positive mood states, such as excitement, interest, and enthusiasm; negative affectivity is the tendency to experience negative mood states, such as sadness, fear, and anger. The PANAS includes two 10-item scales, one assessing positive and the other negative affectivity. Each item is rated on afive-pointscale (1 = very slightly or not at all to 5 = extremely).

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Health care variables. The Health Care EvalTwo factors, hypochondriacal sympuation Scale developed for this study consists toms and impairment in functioning, acof items to assess utilization of care, adher- counted for most of the items making up the ence to care, treatment response, satisfaction Illness Attitude Scales. This confirmed results with care, and attitude toward the physician. from previous clinical samples (Speckens, Each area is represented by two to five items Spinhoven, Sloekers, Bolk, & van Hemert, rated on Likert scales (1 = definitely true to 5 1996; Speckens, 2001). The hypochondria= definitely false). Items for rating utilization cal symptoms factor consisted of 16 items of care, treatment response, and satisfaction with loadings ranging from .55 to .84, and with care were previously shown to have va- the functional impairment factor was comlidity (Noyes, Langbehn, Happel, Sieren, & posed of three items with loadings from .87 Mller, 1999; Safran et al., 1998). to .94. The CFI index was .82 (Goffin, 1993; C Bentler, 1995), suggesting substantial Patients were also asked the extent to Hu which their physicians viewed their health but imperfect goodness-of-fit (Hu & Bentler, problems as legitimate and sanctioned the 1995). sick role. These items covered the privilegWe hypothesized five factors for the es and responsibilities of a social role often Health Care Evaluation Scale consistent with denied hypochondriacal patients (Horvath, item content. Such factors were supported by Gaston, &C Luborsky, 1993; Rief C Sharp, our analysis. Item loadings on individual fac2004). They were rated on five-point scales tors ranged from .53 to .92. The CFI index (1 = not at all to 5 = extremely). was .95, suggesting good fit to the observed item relationships. Scores representing the Analyses unweighted sum of responses were calculated for each factor. Correlations between factors based on these scores ranged from r Confirmatory factor analyses. We conduct- - .07 (between adberence to care and utilizaed confirmatory factor analyses of ordinal tion of care) to r = .67 (between satisfaction variables to examine the structure of the with care and attitude toward physician). Physician-Patient Relationship Scale, Illness Attitude Scales, and Health Care Evaluation Regression analyses. To test the main hypothScale. Technically, the analyses were based esis, we fit a linear model to predict patient on the estimated polychoric correlation ma- ratings on the Physician-Patient Relationship trices of hypothesized, latent, normally dis- Scale (PPRS). The null hypothesis specified a tributed traits corresponding to each item's lack of relationship between the Illness Attiresponse (Muthen, 1979; Muthen, 1984). tude Scales (IAS) hypochondriacal symptoms The program Mplus 2.0 was used (Watson, and the PPRS quality of relationship. The Clark, & Tellegen, 1988). model controlled for potential confounders: We hypothesized a single Physician- age, gender, years of education, presence of Patient Relationship Scale quality of re- a primary physician, duration of relationlationship factor based on the literature ship with that physician (coded on an ordishowing a single dimension in most patient nal scale 0 = no primary physician, 1 = less ratings of physician qualities (e.g., skills, per- than one year, 2 = one year, 3 = two years, 4 sonal characteristics) (Saultz &c Albedaiwi, = three years, and 5 = four or more years), 2004). Such a factor, composed of 28 items number of pbysician visits in the past year with loadings ranging from .58 to .90, was (truncated at 20 to reduce outlier influence), confirmed by our analysis. One item loaded BFI neuroticism score, and PANAS negaweakly and was eliminated. The remaining tive and positive affectivity scores. Statistical items are shown in Table 1. The CFI index adjustment for demographic and physician was .94 (Bentler, 1990; Goffin, 1993). contact variables was subject to limited ex-

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TABLE 2. Correlations Between Items Reflecting Denial of the Sick Role and Both Hypochondriacal Symptoms and Quality of Physician-Patient Relationship Hypochondriacal Symptoms How much does your doctor think you exaggerate health problems? How fully does your doctor feel you cooperate with treatments?" How much does your doctor hlame you for health prohlems you have? How much does your doctor question your desire to get hetter? Note. "Scoring of this item reversed. *p <.O1. **p <.O1. ***p <.OOO1. .35*** .20** .16* .04 Quality of Physician-Patient Relationship -.31*** -.58*** -.32*** .08

ploratory analysis. This was done prior to introducing the IAS hypochondriacal symptoms measure into the model to avoid biasing inference regarding the main hypothesis. Polynomial effects of the number of doctor visits were also examined. The final model utilized hnear and quadratic terms for total doctor visits. Control for the other ratings was planned in advance. We checked the final model for satisfaction of linear regression assumptions and the influence of outliers. Since deletion of candidate outhers had no substantive effect on the estimates of primary interest, we retained all available complete data.

and illness factors were: r = .04, p - .4826 for severity of health problems; r = -.14, p = .0185 for level of somatic symptoms (SSI); and r = -.07, p = .2436 for level of functional impairment (IAS). Correlations between tbe PPRS and dispositional variables were: r = -.14, p = .0156 for neuroticism; r = -.25, p .0089 for negative affectivity; and r = .23, p <.OOO1 for positive affectivity. Hypochondriacal symptoms were also negatively correlated with PPRS quality of relationship scores (r = -.24, p <.OOO1). Also, a significantly larger proportion of patients with high hypochondriasis scores (top 10%) had PPRS scores indicative of a poor physician-patient relationship (bottom 10%) than did those with low hypochondriasis scores RESULTS (bottom 90%) (27% vs. 8%, p = .003). Individual PPRS items that showed the strongest correlations with the IAS hypochondriacal Scores on the PPRS scale ranged from symptoms scale were: How possible is it that 58 to 140 with a mean ( SD) of 110.8 your doctor has overlooked something? r = 16.9. Physician relationship variables were -.34, p <.OOO1); How certain are you that significantly related to PPRS scores but de- your doctor will be there when you need him mographic variables were not. Patients with or her? r = -.28, p .<0001; How thorough is a primary physician had a higher mean qual- your doctor in examining you? r - -.25, p ity of relationship scores than those who <.OOO1; How knowledgeable is your doctor? did not (114.0 15.7 vs. 101.5 * 16.6, p < r - -.23, p <.OOO1; and How much help does .0001). Also, those who had been with their your doctor give you in dealing with health primary physicians longer had higher quality problems? r = -.23, p <.OOO1). of relationship scores (Spearman r = .34, p As shown in Table 2, ratings of indi<.OOO1) as did those who had more visits to vidual items reflecting perceived physician their physician in the past year (Spearman r denial of the sick role were positively cor= .34,p<.0001). related with IAS hypochondriacal symptoms Scores on the PPRS were relatively un- and negatively correlated with PPRS quality related to patient illness variables but were of patient-physician relationship. weakly correlated with dispositional variables. Correlations between this measure

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TABLE 3. Correlations Between Demographic, Health, and Healthcare Variables with Hypochondriacal Symptoms
Hypochondriacal Symptoms
Age .00

p .94 .03 .04

Education Income Somatic Symptoms Impairment in Functioning Perceived Severity of Health Problems Utilization of Care Treatment Response Satisfaction with Care

-.13 -.12
.48 .51 .28 ,31

<.OOO1 <.O0Ol <.OOO1 <.OOO1 <.OOO1 <.OOO1

-.37 -.40

Table 3 shows correlations between IAS hypochondriacal symptoms and other illness and health care variables. Hypochondriacal symptoms were strongly correlated with somatic symptoms and functional impairment. They were positively correlated with utilization of care but negatively correlated with treatment response and satisfaction with care. Table 4 shows the linear regression model of physician-patient relationship quality. The final model explained 22% of the variance in PPRS scores. Significant predictors included all of the relationship variables (having a primary physician, length of relationship, and frequency of physician visits) as well as one of the dispositional variables (positive affectivity). Hypochondriacal symptoms also remained significant in the predictive model. DISCUSSION We showed that among family medicine patients, hypochondriacal symptoms are associated with a less therapeutic patient-physician relationship. To our knowledge, this is the first such demonstration. It is widely assumed that hypochondriacal patients have a less than positive relationship with their physicians, but there has been lit-

tle documentation (Lipsitt, 2001). Of course, the concept of perceived relationship quality that we based our measure on overlaps that of health care satisfaction, and previous studies have shown that patients with hypochondriasis are less satisfied with their care than those who are not hypochondriacal (Barsky, Cleary et al., 1992; Noyes, Kathol, Fisher, Phillips, Suelzer, & Holt, 1993; Twemlow, Branshaw, Coyne, & Lerma, 1993). For instance. Noyes, Stuart and colleagues (2003) found a negative correlation between hypochondriacal symptoms and satisfaction with care (-.36) among general medical patients. Correlations between such symptoms and patient ratings of physician knowledge and concern were similarly in the negative direction (-.23 and -.22 respectively). The association between hypochondriacal symptoms and less therapeutic physician-patient relationship may have several explanations. It may be related to attitudes held by the patient, the physician, or their interaction. Hypochondriacal patients, for their part, suffer from low self-esteem (Starcevic, 1991; Noyes, Watson et al., 2004). They view themselves as unworthy of care and, as a consequence, are mistrustful of any physician who might reassure them (Starcevic, 1990; Wahl, 1963). Their demands for reassurance are in response to unmet needs, yet often serve to alienate those who might

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TABLE 4. Regression Model for Physician-Patient Relationship


Parameter Intercept Age Gender Education Primary Physician - Yes Primary Physician - No Length of Relationship' Frequency of Physician Visits Hypochondriacal Symptoms Neuroticism Negative Affectivity Positive Affectivity 'Refers to physician-patient relationship Estimate 79.06 0.02 2.28 0.03 6.02 0.00 1.50 1.58 -0.31 0.02 -0.01 0.51 Standard t 7.76 0.19 1.10 0.09 2.07

P
<.OO01 0.8501 0.2731 0.9272 0.0396

10.19 0.08 2.07 0.32 2.91

0.64 0.65
0.11 0.30 0.15 0.13

2.34 2.45 -2.82 0.06 -0.07 3.84

0.0199 0.0149 0.0051 0.9502 0.9445 0.0002

fulfill them. Many physicians, in contrast, adhere to the biomdical model of disease (Fabrega, 1990). For them, illness and sick role behavior without organic disease are not so much legitimate medical concerns as they are behaviors for which patients bear responsibility. Among our patients, hypochondriacal symptoms were associated with perceived denial of the sick role, a perception that may have undermined the therapeutic relationship. However, no causal relationship has been established, and a less therapeutic physician-patient relationship may contribute to hypochondriacal concerns in some patients. Other factors may also have independently contributed to both hypochondriasis and negative perception of the physician-patient relationship. In this study, we showed that dispositional variables (neuroticism, negative affectivity, and positive affectivity) are related to relationship quality (Noyes, Kukoyi, Longley, Langbehn, Stuart, submitted). One of them, neuroticism, is strongly related to hypochondriasis, but other variables that we did not examine, such as attachment style, may have influenced ratings as well (Noyes, Watson et al, 2004). According to biomdical theory developed in the eighteenth and nineteenth centu-

ries with the rise of scientific medicine, the subjective experience of illness is the result of underlying organ system disease (Fabrega, 1990; Kirmayer, 1988). Persons who manifest illness behavior without organic disease are poorly accounted for in this system and are, as a consequence, devalued and stigmatized. Often hypochondriacal patientswho present illness without diseaseare told only what they do not have, and that their symptoms are "in their heads" or psychiatric in nature. Frequently, no diagnosis is made nor is any explanation for symptoms offered, and what may have been intended to reassure instead alienates. What transpires between patient and doctor may do more to support biomdical theory than to benefit persons with hypochondriasis (Rief & Sharp, 2004). However, this need not be the case. According to Starcevic (1990), medical reassurance may be accepted in the context of a therapeutic physician-patient relationship. For patients who lack self-esteem and have negative expectations of themselves and others, such a relationship may be more important than removal of symptoms (Starcevic, 1991; Wahl, 1963). To estabhsh such a relationship, the physician must indicate to the patient that his or her symptoms are real and taken seriously (Kessel, 1979). The phy-

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sician must base his or her treatment upon empathy and understanding. He or she must aim to foster a sense of acceptance, trust and commitment to the patient's well-being (Starcevic, 2002; Wahl, 1963). The patient who feels accepted and safe in a therapeutic relationship will be receptive to an explanation for his or her symptoms and will be, in some measure, reassured. The measure of the therapeutic relationship developed for this study elicits from patients' perception of these very qualities. It asks them to rate level of understanding, acceptance, trust, and commitment to well-being (Table 1). It includes those elements that have historically been considered significant for healing and for psychotherapeutic relationships (Jackson, 1999). The importance of these characteristics is not limited to such relationships but extends to those involving most physicians in many settings, as our ratings indicate. In general, these relationships received strongly positive ratings that increased as contact with a particular physician increased. Such relationships appear to have great potential for healing (Noyes, Watson et al., 2004; Wahl, 1963). Yet, it is apparent that hypochondriacal doubts may erode their reassuring power. This study has a number of limitations. Because some patients declined participation and others failed to return questionnaires, the sample may have been less than representative of the clinical population studied. The instrument used to assess the physicianpatient relationship was developed for this study and its psychometric properties are not well-studied. Nevertheless, scores on the measure were associated with a number of clinical variables (e.g., having a primary physician, length of relationship with that physician) indicative of validity. In addition, several potentially important variables were not measured, including an objective assessment of physical conditions and physician characteristics. The amount of variance explained in the therapeutic relationship scale was relatively small (22%) and might have increased with the addition of such important factors.

Also, the extent to which medical care in the population studied involved patients' primary physicians likely varied, thereby influencing ratings in unknown ways. Finally, the study relied upon self-report, and tendencies to view oneself and one's environment negatively may have contributed to the observed relationship between hypochondriacal symptoms and physician-patient relationship. Controlled trials have shown modest benefit from cognitive behavioral therapy and serotonin reuptake inhibitors for patients with hypochondriasis (Barsky & Ahern, 2004; Falln, Petkova, & Sritskaya, 2008; Thomson and Page, 2007). However, such therapy is not widely available and is not always acceptable to patients. Regardless, most hypochondriacal patients are best managed by their primary physicians. To develop or maintain a positive relationship, the physician should legitimize and offer plausible explanation for the patient's symptoms. Regularly scheduled visits demonstrate the physician's commitment and make the presentation of new or more severe symptoms on the part of the patient unnecessary. Caution with respect to diagnostic labels, repeated investigations, and prescribing of agents with dependence potential is also wise. The goal of such management is not to remove symptoms but to help the patient cope with them. He or she needs help in developing meaningful work and leisure activities that divert attention from symptoms and medical care. A therapeutic relationship may be difficult to maintain, but it is the key to successful management. Specific treatment for hypochondriasis is best delivered by professionals trained in cognitive behavioral therapy as well as psychotropic medication that is available in clinics where the patients are being seen. This vastly improves acceptability among patients who are reluctant to view their symptoms as psychiatric. When a therapist is present in the same clinic, it reassures the patient that this person is known and respected and that the physician is going to remain involved. Referral to such a therapist is facilitated by

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a non-pejorative explanation of symptoms and an assurance that the treatments work (Noyes, 2009). Further work is needed to learn which attitudes, personality traits, and attachment styles influence the quality of relationships between hypochondriacal patients and their physicians. Studies are needed to learn how various factors interact over time to influ-

ence outcome. For this purpose, measure of the therapeutic relationship or alliance needs further development. Research in this area should examine a broad array of factors that have potential influence. Ultimately, we seek interventions that improve the therapeutic relationship based on understanding of factors that both weaken and strengthen it.

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