Psychiatry 73(1) Spring 2010 57

Hypochondriacal Symptoms Associated With aLess 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 hypochondria-cal symptoms and the physician-patient relationship. Family medicine patients(w = 310) completed self-report measures of hypochondriacal symptoms, qualityof physician-patient relationship, and variables likely to influence that relation-ship. These variables included physician relationship factors, such as duration ofrelationship and frequency of visits, as well as patient characteristics, such as neu-roticism and positive and negative affectivity. Hypochondriacal symptoms werenegatively correlated {r = -.24) with the quality of physician-patient relationship.In addition to hypochondriacal symptoms, the regression model included havinga primary physician, length of relationship with that physician, frequency of phy-sician visits, and the level of positive affectivity in the patient. Hypochondriacalsymptoms appear to be associated with a less therapeutic physician-patient rela-tionship. Physicians must recognize symptoms of this kind in order to properlyaddress the relationship needs of their patients.

Hypochondriasis or health anxiety is care, including patient reassurance or lacka preoccupation with the fear of having, or thereof.the belief that one has, a serious disease de- According to the interpersonal modelspite evidence to the contrary. So defined, the of hypochondriasis, fear of disease and so-disorder affects between 2 and 7 percent of matic symptoms are expressions of distresspatients attending primary care clinics and aimed at eliciting reassurance from others,is a cause of physical dysfunction and dis- especially primary care physicians (Balint,ability (American Psychiatric Association, 1972; Henderson, 1974). The disorder de-1994). It is also a reason for increased health velops in those with insecure attachment orcare utilization and dissatisfaction with care relationship styles resulting from childhoodreceived. Disorders such as hypochondriasis exposure to inadequate parenting (Stuart 6cmay influence the relationship that develops Noyes, 1999). The person with such a stylebetween patient and physician, and that re- forms a lasting image of him- or herself aslationship may in turn affect the outcome of 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 ofPsychiatry, College of Medicine, College of Public Health at the University of Iowa in Iowa City. Douglas Langbehnis 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 Psychiatryand Behavioral Science at the University of California Davis in Sacramento.

Address correspondence to Russell Noyes, MD, Psychiatry Research, Medical Education Bldg., Iowa City, IA52242-1000; e-mail: russell-noyes@uiowa.edu

58 Hypochondriasis and Physician-Patient Relationship

ing or unable to provide it (Bowlby, 1975;Griffin & Bartholomew, 1994). Early expe-rience with illness (in oneself or one's fam-ily) increases the likelihood that distress willmanifest somatically.

Evidence for this model of hypochon-driasis is beginning to accumulate (Ciecha-nowski. Walker, Katon, & Russo, 2002;Waldinger, Schulz, Barsky, & Ahern, 2006).For instance. Noyes, Stuart, Langbehn, Hap-pel, Longley, Müller, and Yagla (2003) ob-served a relationship between hypochondria-cal symptoms and insecure attachment stylesamong primary care outpatients. In theirsample, such symptoms were positively cor-related with all the insecure styles, especiallythe fearful style. They were also positivelycorrelated with interpersonal problems butnegatively correlated with reassurance frommedical care. Wearden, Perryman, and Ward(2006) found that those with a preoccupiedattachment style (15%) had significantlyhigher hypochondriasis scores than thosewith other styles. In the general population,Schmidt, Straus, and Braehler (2002) foundhypochondriacal features and multiple phys-ical symptoms in anxiously attached indi-viduals.

Persons with insecure attachment,such as those with hypochondriasis, tend tohave relationships that are problematic andunsatisfactory (Bartholomew, 1997; Noyes,Stuart et al., 2003). Evidence for this comesfrom physicians who find such patients de-manding yet rejecting of help that is offered(Brown & Vaillant, 1981). They typicallydescribe hypochondriacal patients as hav-ing unsubstantiated complaints and as bothdifficult and ungrateful (Barsky, Wyshak, &cKlerman, 1991; Schwenk, Marquez, Lefever,& Cohen, 1989; Hahn, Thompson, Wills,Stern, & Budner, 1994). On the other hand,hypochondriacal patients describe their phy-sicians as uncaring and indifferent to theirdistress (Lin, Katon, Von Korff, Bush, Lip-scomb, Russo, & Wagner, 1991; Persing,Stuart, Noyes, & Happel, 2000; Peters, Stan-ley, Rose, &c Salmon, 1998). To them, physi-cians seem unwilling or unable to solve their

health problems. Many patients report nega-tive encounters during which their symptomsare challenged and requests for help denied.

Yet, the key to treatment of hypochon-driacal patients is this very patient-physicianrelationship. According to Starcevic (1991),medical reassurance is possible when a ther-apeutic relationship exists. Under such cir-cumstances, the patient's mistrust may giveway, and he or she may feel accepted, evennurtured, by the physician. Indeed, what thehypochondriacal patient appears to seek isnot so much removal of symptoms as the ac-ceptance and concern of the doctor (Adler,1981; Barsky, Wyshak, & Klerman, 1991).What is currently lacking is empirical evi-dence of such patient-physician interaction.

The aim of this study is to examinethe association between hypochondriacalsymptoms and the physician-physician re-lationship in a primary care clinic. For thispurpose, we developed a measure of the ther-apeutic relationship. We hypothesized thathypochondriacal symptoms would be associ-ated with a less therapeutic relationship afterother factors infiuencing that relationshiphad been taken into account.

METHODS

Subjects

This study was approved by the Uni-versity of Iowa, College of Medicine's reviewboard. Patients from the University of Iowa,Family Care Center were approached as theyarrived for appointments by an investigator(SLL) who described the study and obtainedwritten consent. Those agreeing to partici-pate were given questionnaires and asked tocomplete and return them in the addressedenvelope provided. Patients age 18 to 65,who received most of their care at the center,were included. Excluded were patients withserious medical or psychiatric conditions orthose who were unable to complete ques-

Noyes et al. 59

tionnaires. A majority of those who acceptedquestionnaires returned them (65%).

A total of 310 subjects returned ques-tionnaires. These included 230 (74%) womenand 80 men with a median age of 36 years.Those who returned the questionnaires dif-fered significantly with respect to age (38years vs. 35 years) and sex (67% women vs.54% men) from those who did not. They hada median 16 years of education and $20,000to $40,000 annual household income. Sub-jects included 48% who were married, 36%single, and 16% divorced or widowed. Withrespect to health problems, 29% reportedthey were not at all serious, 43% not very,23% moderately, and 8% very or extremelyserious. Most were white (94%). A major-ity (74%) reported having a primary doctor,defined as one "who handles most of yourmedical care and you regard as your person-al physician." This doctor had provided carefor a median of one year. Patients reporteda median of four physician visits in the pastyear.

Measures

Quality of physician-patient relationship.The perceived quality of the physician-patientrelationship was assessed by the Physician-Patient Relationship Scale (PPRS) (Table 1).The PPRS was developed to measure rela-tionship quality in the primary care setting.Items for the scale were obtained from theliterature dealing with therapeutic relation-ships and with empathy, affective bond, col-laboration, and so forth, important elementsin such relationships (Balint, 1972; Frank,1991; Horvath, Gaston, & Luborsky, 1993;Horvath & Symonds, 1991; Jackson, 1999;Martin, Garske, & Davis, 2000; Seigler &cOsmond, 1974). Existing scales that focuson aspects of therapeutic relationships (e.g.,trust, reassurance, satisfaction, alliance) werealso reviewed for possible items (Anderson& Dedrick, 1990; Hojat, 2007; Horvath &Greenberg, 1989; Safran et al., 1998; Saun-ders, Howard, & Orlinsky, 1989; Speckens,

Spinhoven, van Hemert & Bolk, 2000). Re-sponses were obtained using five-point linearscales (1 = not at all to 5 = extremely). Thefollowing instructions were given: "Whatfollows is a list of questions about the rela-tionship you have with your doctor. Pleaseindicate your answer by circling the appro-priate number to the right of each one. Yourdoctor will not see or have access to your re-sponse." Initial testing was done to removeredundant or ambiguous items. Remainingitems covered the areas of affective bond andcommitment, mutual respect and collabora-tion, reassurance, effective communication,knowledge and skills, and integrity.

Hypochondriacal and somatic symptoms.The Illness Attitude Scales (IAS) is a measureof hypochondriacal symptoms or health anx-iety (Kellner, Abbott, Pathak, Winslow, &Umland, 1983). It consists of 27 items thatassess worry about illness, concerns aboutpain, hypochondriacal beliefs, thanatopho-bia, disease phobia, bodily preoccupations,treatment experience, effects of symptoms,and health habits. They are rated on five-point linear scales (0 = not at all to 4 = almostalways). Studies examining the factor struc-ture of the IAS have identified two factors:hypochondriacal symptoms (health anxiety)and functional impairment (illness behavior)(Speckens, Spinhoven, Sloekers, Bolk, &c vanHemert, 1996; Speckens, 2001).

Somatic symptoms were assessed us-ing the Somatic Symptom Inventory (SSI)(Barsky, Cleary et al., 1992). This measureconsists of 26 items from the MMPI hypo-chondriasis scale and the Symptom Check-list - 90 somatization scale. Responses areobtained on five-point linear scales (1 = notat all to 5 = extremely). Scores on the SSIare strongly correlated with those for hypo-chondriacal symptoms (Barsky, Wyshak, &Klerman, 1986).

Patient dispositional variables. Neuroticismwas measured using the Big Five Inventory(BFI) neuroticism scale (John & Srivastava,1999). The BFI contains 44 items to assess

60 Hypochondriasis and Physician-Patient Relationship

TABLE 1. The Physician-Patient Relationship Scale Showing Factor Loadings for Individual Items

Loading

1. How well does your doctor understand the concerns you have? .90

2. How committed is your doctor to your well-being? .90

3. How completely does your doctor accept you? .90

4. How genuine is your doctor? .90

5. How carefully does your doctor listen to you? .89

6. How much do you trust your doctor? .87

7. How knowledgeable is your doctor? .87

8. How much support or encouragement does your doctor give you? .87

9. How much help does your doctor give you in dealing with health problems? .86

10. If you were to become seriously ill, how confident are you that your doctor would do everything possible? .86

11. How determined is your doctor when dealing with serious health problems? .85

12. How seriously does your doctor take your health problems? .85

13. If you were in pain or were suffering, how sensitive wouid your doctor be? .83

14. How completely does your doctor understand your health problems? .83

15. If you were not feeling well, how sympathetic would your doctor be? .82

16. How well does your doctor explain health problems or treatments to you? .82

17. How respectful is your doctor of you? .82

18. How important does your doctor consider your opinions to be? .81

19. How reassuring is your doctor? .80

20. How thorough is your doctor in examining you? .80

21. How skilled is your doctor in his or her area of practice? .80

22. How much does your doctor care about you as a person? .79

23. How adequate is your doctor's explanation of your symptoms? .78

24. How comfortable is your doctor when examining you? .77

25. How freely can you speak to your doctor about personal matters? .77

26. How hopeful is your doctor about the outcome of your health care? .73

27. How certain are you that your doctor will be there when you need him or her? .70

28. How possible is it that your doctor has overlooked something? .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 correlatedwith the neuroticism scale of the NEO Personality Inventory, the standard for measurementin this area (Costa &c McCrae, 1992).

Positive and negative affectivity were measured using the Positive and Negative AffectSchedule (PANAS) (Watson, Clark, & Tellegen, 1988; Watson, Wiese, Vaidya, & Tellegen,1999). Positive affectivity is the tendency to experience positive mood states, such as excite-ment, interest, and enthusiasm; negative affectivity is the tendency to experience negativemood states, such as sadness, fear, and anger. The PANAS includes two 10-item scales, oneassessing positive and the other negative affectivity. Each item is rated on a five-point scale (1= very slightly or not at all to 5 = extremely).

Noyes et al. 61

Health care variables. The Health Care Eval-uation Scale developed for this study consistsof items to assess utilization of care, adher-ence to care, treatment response, satisfactionwith care, and attitude toward the physician.Each area is represented by two to five itemsrated on Likert scales (1 = definitely true to 5= definitely false). Items for rating utilizationof care, treatment response, and satisfactionwith care were previously shown to have va-lidity (Noyes, Langbehn, Happel, Sieren, &Müller, 1999; Safran et al., 1998).

Patients were also asked the extent towhich their physicians viewed their healthproblems as legitimate and sanctioned thesick role. These items covered the privileg-es and responsibilities of a social role oftendenied hypochondriacal patients (Horvath,Gaston, &C Luborsky, 1993; Rief ÔC Sharp,2004). They were rated on five-point scales(1 = not at all to 5 = extremely).

Analyses

Confirmatory factor analyses. We conduct-ed confirmatory factor analyses of ordinalvariables to examine the structure of thePhysician-Patient Relationship Scale, IllnessAttitude Scales, and Health Care EvaluationScale. Technically, the analyses were basedon the estimated polychoric correlation ma-trices of hypothesized, latent, normally dis-tributed traits corresponding to each item'sresponse (Muthen, 1979; Muthen, 1984).The program Mplus 2.0 was used (Watson,Clark, & Tellegen, 1988).

We hypothesized a single Physician-Patient Relationship Scale quality of re-lationship factor based on the literatureshowing a single dimension in most patientratings of physician qualities (e.g., skills, per-sonal characteristics) (Saultz &c Albedaiwi,2004). Such a factor, composed of 28 itemswith loadings ranging from .58 to .90, wasconfirmed by our analysis. One item loadedweakly and was eliminated. The remainingitems are shown in Table 1. The CFI indexwas .94 (Bentler, 1990; Goffin, 1993).

Two factors, hypochondriacal symp-toms and impairment in functioning, ac-counted for most of the items making up theIllness Attitude Scales. This confirmed resultsfrom previous clinical samples (Speckens,Spinhoven, Sloekers, Bolk, & van Hemert,1996; Speckens, 2001). The hypochondria-cal symptoms factor consisted of 16 itemswith loadings ranging from .55 to .84, andthe functional impairment factor was com-posed of three items with loadings from .87to .94. The CFI index was .82 (Goffin, 1993;Hu ÔC Bentler, 1995), suggesting substantialbut imperfect goodness-of-fit (Hu & Bentler,1995).

We hypothesized five factors for theHealth Care Evaluation Scale consistent withitem content. Such factors were supported byour analysis. Item loadings on individual fac-tors ranged from .53 to .92. The CFI indexwas .95, suggesting good fit to the observeditem relationships. Scores representing theunweighted sum of responses were calcu-lated for each factor. Correlations betweenfactors based on these scores ranged from r- .07 (between adberence to care and utiliza-tion of care) to r = .67 (between satisfactionwith care and attitude toward physician).

Regression analyses. To test the main hypoth-esis, we fit a linear model to predict patientratings on the Physician-Patient RelationshipScale (PPRS). The null hypothesis specified alack of relationship between the Illness Atti-tude Scales (IAS) hypochondriacal symptomsand the PPRS quality of relationship. Themodel controlled for potential confounders:age, gender, years of education, presence ofa primary physician, duration of relation-ship with that physician (coded on an ordi-nal scale 0 = no primary physician, 1 = lessthan one year, 2 = one year, 3 = two years, 4= three years, and 5 = four or more years),number of pbysician visits in the past year(truncated at 20 to reduce outlier influence),BFI neuroticism score, and PANAS nega-tive and positive affectivity scores. Statisticaladjustment for demographic and physiciancontact variables was subject to limited ex-

62 Hypochondriasis and Physician-Patient Relationship

TABLE 2. Correlations Between Items Reflecting Denial of the Sick Role and Both Hypochondriacal Symptoms

and Quality of Physician-Patient Relationship

Quality ofHypochondriacal Physician-Patient

Symptoms Relationship

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

-.31***

-.58***

-.32***

.08

ploratory analysis. This was done prior tointroducing the IAS hypochondriacal symp-toms measure into the model to avoid bias-ing inference regarding the main hypothesis.Polynomial effects of the number of doctorvisits were also examined. The final modelutilized hnear and quadratic terms for totaldoctor visits. Control for the other ratingswas planned in advance.

We checked the final model for satis-faction of linear regression assumptions andthe influence of outliers. Since deletion ofcandidate outhers had no substantive effecton the estimates of primary interest, we re-tained all available complete data.

RESULTS

Scores on the PPRS scale ranged from58 to 140 with a mean (± SD) of 110.8 ±16.9. Physician relationship variables weresignificantly related to PPRS scores but de-mographic variables were not. Patients witha primary physician had a higher mean qual-ity of relationship scores than those whodid not (114.0 ± 15.7 vs. 101.5 * 16.6, p <.0001). Also, those who had been with theirprimary physicians longer had higher qualityof relationship scores (Spearman r = .34, p<.OOO1) as did those who had more visits totheir physician in the past year (Spearman r= .34,p<.0001).

Scores on the PPRS were relatively un-related to patient illness variables but wereweakly correlated with dispositional vari-ables. Correlations between this measure

and illness factors were: r = .04, p - .4826for severity of health problems; r = -.14, p =.0185 for level of somatic symptoms (SSI);and r = -.07, p = .2436 for level of functionalimpairment (IAS). Correlations between tbePPRS 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 alsonegatively correlated with PPRS quality ofrelationship scores (r = -.24, p <.OOO1). Also,a significantly larger proportion of patientswith high hypochondriasis scores (top 10%)had PPRS scores indicative of a poor physi-cian-patient relationship (bottom 10%) thandid those with low hypochondriasis scores(bottom 90%) (27% vs. 8%, p = .003). Indi-vidual PPRS items that showed the strongestcorrelations with the IAS hypochondriacalsymptoms scale were: How possible is it thatyour doctor has overlooked something? r =-.34, p <.OOO1); How certain are you thatyour doctor will be there when you need himor her? r = -.28, p .<0001; How thorough isyour doctor in examining you? r - -.25, p<.OOO1; How knowledgeable is your doctor?r - -.23, p <.OOO1; and How much help doesyour doctor give you in dealing with healthproblems? r = -.23, p <.OOO1).

As shown in Table 2, ratings of indi-vidual items reflecting perceived physiciandenial of the sick role were positively cor-related with IAS hypochondriacal symptomsand negatively correlated with PPRS qualityof patient-physician relationship.

Noyes et al. 63

TABLE 3. Correlations Between Demographic, Health, and Healthcare Variables withHypochondriacal Symptoms

Hypochondriacal Symptoms p

.94

.03

.04

<.OOO1

<.O0Ol

<.OOO1

<.OOO1

<.OOO1

<.OOO1

Age

Education

Income

Somatic Symptoms

Impairment in Functioning

Perceived Severity of Health Problems

Utilization of Care

Treatment Response

Satisfaction with Care

.00

-.13

-.12

.48

.51

.28

,31

-.37

-.40

Table 3 shows correlations betweenIAS hypochondriacal symptoms and otherillness and health care variables. Hypochon-driacal symptoms were strongly correlatedwith somatic symptoms and functional im-pairment. They were positively correlatedwith utilization of care but negatively corre-lated with treatment response and satisfac-tion with care.

Table 4 shows the linear regressionmodel of physician-patient relationshipquality. The final model explained 22% ofthe variance in PPRS scores. Significant pre-dictors included all of the relationship vari-ables (having a primary physician, length ofrelationship, and frequency of physician vis-its) as well as one of the dispositional vari-ables (positive affectivity). Hypochondriacalsymptoms also remained significant in thepredictive model.

DISCUSSION

We showed that among family medi-cine patients, hypochondriacal symptomsare associated with a less therapeutic pa-tient-physician relationship. To our knowl-edge, this is the first such demonstration. Itis widely assumed that hypochondriacal pa-tients have a less than positive relationshipwith their physicians, but there has been lit-

tle documentation (Lipsitt, 2001). Of course,the concept of perceived relationship qualitythat we based our measure on overlaps thatof health care satisfaction, and previous stud-ies have shown that patients with hypochon-driasis are less satisfied with their care thanthose who are not hypochondriacal (Barsky,Cleary et al., 1992; Noyes, Kathol, Fisher,Phillips, Suelzer, & Holt, 1993; Twemlow,Branshaw, Coyne, & Lerma, 1993). For in-stance. Noyes, Stuart and colleagues (2003)found a negative correlation between hypo-chondriacal symptoms and satisfaction withcare (-.36) among general medical patients.Correlations between such symptoms andpatient ratings of physician knowledge andconcern were similarly in the negative direc-tion (-.23 and -.22 respectively).

The association between hypochon-driacal symptoms and less therapeutic phy-sician-patient relationship may have severalexplanations. It may be related to attitudesheld by the patient, the physician, or theirinteraction. Hypochondriacal patients, fortheir part, suffer from low self-esteem (Star-cevic, 1991; Noyes, Watson et al., 2004).They view themselves as unworthy of careand, as a consequence, are mistrustful of anyphysician who might reassure them (Star-cevic, 1990; Wahl, 1963). Their demands forreassurance are in response to unmet needs,yet often serve to alienate those who might

64 Hypochondriasis and Physician-Patient Relationship

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

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

10.19

0.08

2.07

0.32

2.91

0.64

0.65

0.11

0.30

0.15

0.13

t

7.76

0.19

1.10

0.09

2.07

2.34

2.45

-2.82

0.06

-0.07

3.84

P<.OO01

0.8501

0.2731

0.9272

0.0396

0.0199

0.0149

0.0051

0.9502

0.9445

0.0002

'Refers to physician-patient relationship

fulfill them. Many physicians, in contrast,adhere to the biomédical model of disease(Fabrega, 1990). For them, illness and sickrole behavior without organic disease arenot so much legitimate medical concerns asthey are behaviors for which patients bearresponsibility. Among our patients, hypo-chondriacal symptoms were associated withperceived denial of the sick role, a perceptionthat may have undermined the therapeuticrelationship.

However, no causal relationship hasbeen established, and a less therapeutic phy-sician-patient relationship may contribute tohypochondriacal concerns in some patients.Other factors may also have independentlycontributed to both hypochondriasis andnegative perception of the physician-patientrelationship. In this study, we showed thatdispositional variables (neuroticism, negativeaffectivity, and positive affectivity) are relat-ed to relationship quality (Noyes, Kukoyi,Longley, Langbehn, Stuart, submitted). Oneof them, neuroticism, is strongly related tohypochondriasis, but other variables that wedid not examine, such as attachment style,may have influenced ratings as well (Noyes,Watson et al, 2004).

According to biomédical theory devel-oped in the eighteenth and nineteenth centu-

ries with the rise of scientific medicine, thesubjective experience of illness is the resultof underlying organ system disease (Fabrega,1990; Kirmayer, 1988). Persons who mani-fest illness behavior without organic diseaseare poorly accounted for in this system andare, as a consequence, devalued and stigma-tized. Often hypochondriacal patients—whopresent illness without disease—are told onlywhat they do not have, and that their symp-toms are "in their heads" or psychiatric innature. Frequently, no diagnosis is made noris any explanation for symptoms offered, andwhat may have been intended to reassureinstead alienates. What transpires betweenpatient and doctor may do more to supportbiomédical theory than to benefit personswith hypochondriasis (Rief & Sharp, 2004).

However, this need not be the case.According to Starcevic (1990), medical re-assurance may be accepted in the contextof a therapeutic physician-patient relation-ship. For patients who lack self-esteem andhave negative expectations of themselvesand others, such a relationship may be moreimportant than removal of symptoms (Star-cevic, 1991; Wahl, 1963). To estabhsh sucha relationship, the physician must indicate tothe patient that his or her symptoms are realand taken seriously (Kessel, 1979). The phy-

Noyes et al. 65

sician must base his or her treatment uponempathy and understanding. He or she mustaim to foster a sense of acceptance, trust andcommitment to the patient's well-being (Star-cevic, 2002; Wahl, 1963). The patient whofeels accepted and safe in a therapeutic rela-tionship will be receptive to an explanationfor his or her symptoms and will be, in somemeasure, reassured.

The measure of the therapeutic rela-tionship developed for this study elicits frompatients' perception of these very qualities. Itasks them to rate level of understanding, ac-ceptance, trust, and commitment to well-be-ing (Table 1). It includes those elements thathave historically been considered significantfor healing and for psychotherapeutic rela-tionships (Jackson, 1999). The importanceof these characteristics is not limited to suchrelationships but extends to those involv-ing most physicians in many settings, as ourratings indicate. In general, these relation-ships received strongly positive ratings thatincreased as contact with a particular phy-sician increased. Such relationships appearto have great potential for healing (Noyes,Watson et al., 2004; Wahl, 1963). Yet, it isapparent that hypochondriacal doubts mayerode their reassuring power.

This study has a number of limitations.Because some patients declined participationand others failed to return questionnaires,the sample may have been less than repre-sentative of the clinical population studied.The instrument used to assess the physician-patient relationship was developed for thisstudy and its psychometric properties arenot well-studied. Nevertheless, scores on themeasure were associated with a number ofclinical variables (e.g., having a primary phy-sician, length of relationship with that physi-cian) indicative of validity. In addition, sev-eral potentially important variables were notmeasured, including an objective assessmentof physical conditions and physician charac-teristics. The amount of variance explainedin the therapeutic relationship scale was rela-tively small (22%) and might have increasedwith the addition of such important factors.

Also, the extent to which medical care in thepopulation studied involved patients' pri-mary physicians likely varied, thereby influ-encing ratings in unknown ways. Finally, thestudy relied upon self-report, and tendenciesto view oneself and one's environment nega-tively may have contributed to the observedrelationship between hypochondriacal symp-toms and physician-patient relationship.

Controlled trials have shown modestbenefit from cognitive behavioral therapyand serotonin reuptake inhibitors for pa-tients with hypochondriasis (Barsky & Ah-ern, 2004; Fallón, Petkova, & Sritskaya,2008; Thomson and Page, 2007). However,such therapy is not widely available and isnot always acceptable to patients. Regard-less, most hypochondriacal patients are bestmanaged by their primary physicians. To de-velop or maintain a positive relationship, thephysician should legitimize and offer plau-sible explanation for the patient's symptoms.Regularly scheduled visits demonstrate thephysician's commitment and make the pre-sentation of new or more severe symptomson the part of the patient unnecessary. Cau-tion with respect to diagnostic labels, repeat-ed investigations, and prescribing of agentswith dependence potential is also wise. Thegoal of such management is not to removesymptoms but to help the patient cope withthem. He or she needs help in developingmeaningful work and leisure activities thatdivert attention from symptoms and medicalcare. A therapeutic relationship may be dif-ficult to maintain, but it is the key to success-ful management.

Specific treatment for hypochondriasisis best delivered by professionals trained incognitive behavioral therapy as well as psy-chotropic medication that is available in clin-ics where the patients are being seen. Thisvastly improves acceptability among patientswho are reluctant to view their symptoms aspsychiatric. When a therapist is present inthe same clinic, it reassures the patient thatthis person is known and respected and thatthe physician is going to remain involved.Referral to such a therapist is facilitated by

66 Hypochondriasis and Physician-Patient Relationship

a non-pejorative explanation of symptomsand an assurance that the treatments work(Noyes, 2009).

Further work is needed to learn whichattitudes, personality traits, and attachmentstyles influence the quality of relationshipsbetween hypochondriacal patients and theirphysicians. Studies are needed to learn howvarious factors interact over time to influ-

ence outcome. For this purpose, measure ofthe therapeutic relationship or alliance needsfurther development. Research in this areashould examine a broad array of factors thathave potential influence. Ultimately, we seekinterventions that improve the therapeuticrelationship based on understanding of fac-tors that both weaken and strengthen it.

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