Health Attitude Survey

A Scale for Assessing Somatizing Patients

RUSSELL NOYES, JR., M.D., DOUGLAS R. LANGBEHN, M.D., PH.D.

RACHEL L. HAPPEL, B.S.N., LORI R. SIEREN, B.S.N.
BARBARA A. MULLER, M.D.

The authors designed an instrument, the Health Attitude Survey, to assess somatization, and ad-
ministered it to over 1,000 patients attending a general medicine clinic. Within this population, a
series of somatizing patients and control patients were identified for purposes of developing and
testing the instrument. The 27-item scale was rapidly administered and acceptable to the pa-
tients. Based on comparisons with other measures of somatization, the instrument appeared to be
a valid measure of the attitudes and perceptions of somatizing patients, and it distinguished these
patients from the control subjects. The measure showed acceptable predictive value and may
prove useful in clinical settings, where rapid screening is desired.
(Psychosomatics 1999; 40:470–478)

S omatization, the somatic expression of psychological

distress, occurs in a sizable proportion of primary care
patients.1,2 It is a large problem and source of frustration
for both physicians and patients. Given the magnitude and
concerns about containing health care costs and at the same
time improving patient satisfaction, the problem of soma-
tization appears to have been neglected.3 Among the rea-
sons for this neglect are difficulty in recognizing somatiz-
ing patients and the lack of specific treatment for their
problems. Poor recognition extends to most psychiatric dis-
orders and is a larger problem that, despite considerable
research and discussion, remains largely unsolved.4 So-
matization contributes to poor recognition because most
psychiatric patients (e.g., those with anxiety and depres-
sion) present with somatic symptoms.5–7
Received January 2, 1999; revised March 22, 1999; accepted June 14,
1999. From the Departments of Psychiatry, Preventative Medicine and
Environmental Health, and Internal Medicine, University of Iowa College
of Medicine; and from the University of Iowa Hospitals and Clinics and
Veterans Administration Medical Center, Iowa City, Iowa. Address cor-
respondence and reprint requests to Dr. Noyes, University of Iowa Col-
lege of Medicine, Psychiatry Research, MEB, Iowa City, IA 52242–1000.
Copyright q 1999 The Academy of Psychosomatic Medicine.
Three approaches have been taken to the assessment of
somatization in primary care. One involves instruments to
identify psychiatric disorders in general. The General Health
Questionnaire (GHQ) is an example of self-administered
scales designed for this purpose, and more recently, brief
structured interviews such as the Primary Care Evaluation of
Mental Disorders (PRIME-MD) have been developed.8,9
Both elicit information about somatic symptoms and identify
somatoform, as well as other psychiatric, disorders.
Another approach involves identification of unex-
plained somatic symptoms. The diagnostic criteria of Bri-
quet’s syndrome and, subsequently, somatization disorder,
included such symptoms that were incorporated into di-
agnostic interviews and checklists.10–12 Although DSM-III-
R called for at least 14 symptoms in women and 12 in men,
Escobar et al. showed that a lower threshold of 6 and 4 for
women and men, respectively, identified patients who had
similar demographic and illness characteristics.13–15 And,
several abbreviated checklists have been used to more ef-
ficiently screen for these patients.16–18
A third approach began with development of the Whi-
teley Index. This measure consists of 14 items that Pi-

470 Psychosomatics 40:6, November-December 1999


lowsky found distinguished hypochondriacal from non-
hypochondriacal psychiatric patients.19 Subsequently,
Pilowsky and Spence added items to measure related ill-
ness attitudes and concerns.20 The resulting Illness Behav-
iour Questionnaire (IBQ) contains 62 binary items distrib-
uted among seven factors.21 The instrument has been
widely used to examine various aspects of illness behavior
and has been shown to have adequate psychometric prop-
erties.22,23 However, the IBQ is lengthy and may be influ-
enced by serious disease.24,25
We developed a brief measure for the evaluation of
somatization. Items were constructed from the literature on
somatization, especially reviews of Lipowski.26–28 In-
cluded were items having to do with psychological distress,
somatic symptom presentation, and health care utilization.
Not included were items on specific somatic symptoms.
Several items involved how thoroughly symptoms had
been evaluated and explained. This was an effort—unique
with this scale—to learn how accurate somatizing patients
might be in identifying themselves. Also, a number of
items focused on interaction with physicians and satisfac-
tion with medical care, both aspects neglected in prior
scales. Our purpose was to develop and test the instrument
in a primary care population.
METHODS
Subjects
Subjects for this investigation were obtained from the
Medicine Clinic of the University of Iowa Hospitals and
Clinics. New patients on certain days of the week were
asked to complete questionnaires as they arrived for ap-
pointments. Patients who screened positively on the Patient
Questionnaire of the PRIME-MD or Illness Worry Scale
were contacted by telephone for follow-up interviews, us-
ing the Clinician Evaluation Guide of the PRIME-MD and
the somatoform disorders module of the Structured Clinical
Interview for DSM-IV.9,12,29 Patients who presented with
somatic symptoms and met criteria for a somatoform, anxi-
ety, or depressive disorder made up the somatizing group.30
Patients from the same clinic who scored negatively on the
same questionnaires or who, when interviewed, were found
not to have a somatic presentation or a somatoform, anxi-
ety, or depressive disorder made up the control group. Con-
trol subjects were randomly selected from consecutively
screened patients. Also, patients who screened positively
on questionnaires were eligible for assignment to the con-
Psychosomatics 40:6, November-December 1999
Noyes et al.
trol group, providing they did not have a somatic presen-
tation and did not meet diagnostic criteria.
Over a 1-year period (1997), about 2,800 new patients
were seen in the Medicine Clinic on the days that screening
took place. Of these, 1,010 completed the questionnaires
and were included in the overall sample. Some of the re-
maining patients did not receive questionnaires, whereas
others appeared not to have time or preferred not to com-
plete them. A few who completed questionnaires were ex-
cluded on account of severe physical illness and other rea-
sons (e.g., did not speak English). Of those who were
approached after screening, nearly half agreed to be inter-
viewed, whereas the remainder could not be reached or
refused further participation. The screened sample of 1,010
patients included 610 women and 400 men who had a
mean 5 standard deviation (SD) age of 43.0 5 12.8. In
this group of 141 somatizers, there were 110 women and
31 men who had a mean 5 SD age of 42.2 5 13.0. In the
group of 34 nonsomatizing control subjects, there were 27
women and 7 men who had a mean 5 SD of 45.4 5 12.9.
Instruments
The patients were screened by using the PRIME-MD
developed by Spitzer et al.9 This instrument was designed
to identify mental disorders that are common in primary
care. Its original version consists of two components: a 1-
page Patient Questionnaire and a 12-page Clinician Eval-
uation Guide or structured interview to follow up on posi-
tive responses. The patient questionnaire contains 26
questions about symptoms present during the past month.
These questions are divided into diagnostic areas (soma-
toform, anxiety, depressive, alcohol, and eating disorders)
and include the most common physical complaints in pri-
mary care. For each diagnostic area, a certain number of
positive responses call for administration of the Clinician
Evaluation Guide. This interview was used to make DSM-
III-R diagnoses.31 The subjects were also evaluated by us-
ing the somatoform disorders module of the Structured
Clinical Interview for DSM-IV (SCID).12
The patients were also asked to complete the Illness
Worry Scale developed by Robbins et al.29 This is a 9-item
measure that asks for a yes/no responses. It is a modifica-
tion of the Whiteley Index that eliminates items influenced
by symptoms of physical illness.22 A score of $ 4 was
recommended by Kirmayer and Robbins for the identifi-
cation of hypochondriacal worry.1 The measure is posi-
471
Health Attitude Survey
tively correlated with the Whiteley Index and has adequate
psychometric properties.29
Initial screening also involved administration of a new
instrument, the Health Attitude Survey. This instrument
was developed by the authors to assess the phenomenon of
somatization, defined by Lipowski as “a tendency to ex-
perience and communicate psychological distress in the
form of somatic symptoms and to seek medical help for
them.”28 In accordance with this descriptive definition, we
generated a pool of 36 items covering psychological dis-
tress (psychological distress, excessive health worry); so-
matic symptoms (unexplained symptoms, conflict regard-
ing sick role); and medical care (persistent seeking of care,
dissatisfaction with care). Items from existing scales, such
as the Illness Behavior Questionnaire, Toronto Alexithy-
mia Scale, Health Perceptions Questionnaire, and Organic
Functional Checklist were considered for inclusion.21,32–34
Many items were worded both positively and negatively in
an effort to counter response bias. Responses were obtained
on five-point bidirectional scales of agreement:
04strongly disagree, 14disagree, 24neutral, 34agree,
and 44strongly agree. Three items were added to test the
acceptability of the measure.
Procedures
As the patients arrived at the Medicine Clinic for their
appointments, they were handed screening questionnaires,
including the Patient Questionnaire of the PRIME-MD, the
Illness Worry Scale, and the Health Attitude Survey. A
brief statement on the cover sheet said that the purpose was
to learn more about the attitudes patients have about their
health and medical care. These questionnaires took less
than 10 minutes to complete and, once completed, were
handed to the registration clerk or nurse in attendance.
An attempt was made to contact patients who scored
above established cutoffs for the Patient Questionnaire or
Illness Worry Scale within 7 days of their clinic visit. This
contact was made by telephone to complete the clinician
evaluation portion of the PRIME-MD and the somatoform
disorders module of the SCID. This interview was com-
pleted by two nurses who had been trained in the admin-
istration of the instruments and achieved satisfactory in-
terrater agreement. Because these interviews required
judgment about the extent to which symptoms were ex-
plained by physical disease, the nurses frequently sought
clarification of this from clinic physicians and medical re-
cords, and then reviewed cases with the investigators. The
nurses also determined the extent of somatization, accord-
472
ing to a procedure proposed by Bridges and Goldberg, and
used by Kirmayer and Robbins.1,35
Analyses
We eliminated any Health Attitude Surveys with more
than two missing values. Remaining missing values (which
occurred in about 5% of the subjects) were replaced with
a score of 2 (neutral). As noted earlier, individual items
were scored from 0 to 4. Simplified factor scores and total
scores for the instrument were obtained by summing scores
for individual items. Differences in scores between groups
were examined by using analyses of variance.In the case
of three-way comparisons among somatizing, severely ill,
and control subjects, we used a level of a40.05 and Tu-
key’s standardized range test with adjustment for unequal
sample sizes.36 Where Pearson correlation coefficients
were calculated, the data were further examined for non-
linearity to ensure that the coefficients adequately sum-
marized the two-way interrelationships.
We initially conducted a confirmatory factor analysis
to test a priori hypotheses about the underlying structure
of the Health Attitude Survey.37 Hypothesized dimensions
included psychological distress, excessive health worry,
conflict about sick role, dissatisfaction with health care,
and persistent utilization of care. Although we found con-
siderable evidence for this structure, the proposed conflict
over sick-role factor was not supported. Consequently, we
elected to conduct exploratory factor analyses by using
oblique rotations and a variety of fitting methods (i.e., prin-
cipal components, principal factors, and multivariate nor-
mal marginal likelihood).38 These analyses all gave com-
parable results. The number of factors retained was
determined by scree plot analysis. After initial analyses,
items that correlated only weakly (r,0.40) with all factors
or moderately with more than one factor were eliminated.
(Compared with the oblique [correlated] factor solutions,
orthogonal [uncorrelated] solutions yielded similar struc-
tures and nearly identical assocations. We chose oblique
solutions because they led to slightly more parsimonious
factors that still had only low-to-moderate correlations.)
Also eliminated were items that individually failed to dis-
criminate between the somatizing and the control subjects.
After this, the factor analysis was repeated.
We calculated simplified factor scores by assigning
each item exclusively to the factor with which it correlated
highest. The item scores associated with each factor were
then summed, and these sums were rescaled so that each
would fall within a range from 0 to 1. These simplified
Psychosomatics 40:6, November-December 1999
 Noyes et al.

scores correlated between 0.93 and 0.99 with conventional
(weighted) factor scores (calculated by the various methods
mentioned earlier), indicating that the simplified scoring
was satisfactory for use in further analyses.
We selected a smaller subset of items for screening in
primary care. Our aim was to construct a simple scale by
adding the responses to individual items. To accomplish
this, we performed a forward-selection procedure for
equally weighted predictors developed by one of the au-
thors. This process involves adding the item at each step
that minimizes the standardized mean difference in total
score between the somatizing patients and control subjects.
The method is equivalent to maximizing Student’s t statis-
tic for differences between the groups as each item is

TABLE 1. Factor loadings and mean%standard deviation (SD) scores obtained by somatizing and control subjects on the Health Attitude
Survey1
Mean%SD
Somatizing Control
Factor Subjects Subjects
Loading (N$141) (N$34) ,P
Dissatisfaction with care, 19.6%2
1. I have been satisfied with the medical care I have received. (R) 0.85 1.851.0 1.250.9 0.0005
2. Doctors have done the best they could to diagnose and treat my health
problems. (R) 0.84 1.851.1 1.251.1 0.02
3. Doctors have taken my health problems seriously. 0.80 1.651.0 1.150.9 0.005
4. My health problems have been thoroughly evaluated. (R)3 0.79 2.251.0 1.450.9 0.000
5. Doctors do not seem to know much about the health problems I have
had. 3 0.71 1.951.0 1.050.7 0.0000
6. My health problems have been completely explained. (R)3 0.71 2.551.1 1.551.0 0.0000
7. Doctors seem to think I am exaggerating my health problems. 0.62 1.551.0 0.950.6 0.0001
8. My response to treatment has not been satisfactory. 0.58 1.951.0 1.150.9 0.0001
9. My response to treatment is usually excellent. (R)3 0.48 1.751.0 1.050.6 0.0001
Frustration with ill health, 20.3%
10. I am tired of feeling sick and would like to get to the bottom of my
health problems. 0.90 3.251.1 2.251.1 0.0000
11. I have felt ill for quite a while now.3 0.87 2.851.2 1.451.1 0.0000
12. I am going to keep searching for an answer to my health problems. 0.82 3.051.0 2.251.0 0.0001
13. I do not think there is anything seriously wrong with my body. (R) 0.58 2.251.1 1.651.0 0.005
High utilization of care, 13.6%
14. I have seen many different doctors over the years. 0.77 2.051.3 1.451.2 0.02
15. I have taken a lot of medicine recently. 0.75 1.951.3 1.651.3 NS
16. I do not go to the doctor often. (R) 0.69 1.551.1 1.151.0 0.07
17. I have had relatively good health over the years. 0.59 1.451.2 1.250.8 NS
Excessive health worry, 13.8%
18. I sometimes worry too much about my health. 0.81 1.751.1 1.150.8 0.002
19. I often fear the worst when I develop symptoms. 0.81 1.851.1 1.250.9 0.001
20. I have trouble getting my mind off my health.3 0.77 1.851.2 0.950.6 0.0001
Psychological distress, 13.5%
21. Sometimes I feel depressed and cannot seem to shake it off.3 0.79 2.251.2 1.351.1 0.0001
22. I have sought help for emotional or stress-related problems.3 0.78 2.051.2 1.251.2 0.0001
23. It is easy to relax and stay calm. (R) 0.72 2.451.1 1.651.1 0.0001
24. I believe the stress I am under may be affecting my health. 0.55 2.251.2 1.951.1 NS
Discordant communication of distress, 11.5%
25. Some people think that I am capable of more work than I feel able to
do. 0.84 1.651.3 1.351.1 NS
26. Some people think that I have been sick just to gain attention. 0.67 0.951.0 0.750.7 0.06
27. It is difficult for me to find the right words for my feelings. 0.64 2.051.3 1.151.0 0.0001

Note: NS4not significant; (R)4indicates items reversed for scoring purposes.

1
Items scored on five-point Lkert scales: 04strongly disagree; 14disagree, 24neutral, 34agree; 44strongly agree.
2
Percents indicate the proportion of variance explained by each factor. It should be noted that the factors are not independent.
3
Eight items that collectively best discriminated between somatizing and control patients (see Table 5).

Psychosomatics 40:6, November-December 1999 473

Health Attitude Survey
added. This method has previously performed well for bi-
nary predictors and should yield similar results with Likert-
scored data.39 This selection was performed by using only
the somatizers (N4141) and the control subjects (N434)
identified by structured interview.
RESULTS
The exploratory factor analyses identified six subscales of
the Health Attitude Survey that accounted for 61% of the
variance. Table 1 shows the factors, together with loadings,
for individual items. The factors appeared meaningfully
related to six dimensions of somatization that we labeled
1) dissatisfaction with care, 2) frustration with ill health,
3) high utilization of care, 4) excessive health worry, 5)
psychological distress, and 6) discordant communication
of distress. These factors included 27 of the original 36
items, each having a loading of at least 0.50 (or in one
case, 0.48) on the factor with which it was most closely
associated. Correlation coefficients among factors ranged
from 0.18 to 0.35, with the exception of dissatisfaction with
care and frustration with ill health, for which r40.44.
Table 1 also compares mean scores on individual items
obtained by the somatizers and nonsomatizers. For this
comparison, as for all analyses, the scores of positively
worded items were reversed. Statistically significant dif-
ferences or trends were observed for most items. The so-
matizing patients showed greatest agreement with state-
ments on frustration with ill health. For the statement, “I
think this questionnaire deals with important matters,”
3.5% of the somatizers and 2.9% of the control subjects
expressed disagreement. For “I had no trouble choosing
my answers to most questions,” the respective figures were
11.3% and 5.9%, and for “I was bothered or upset by the
questionnaire,” 2.1% and 0% expressed agreement.
Table 2 compares mean factor scores for the men and
women within the surveyed population (N41,010). The
women achieved significantly higher scores on frustration
TABLE 2. Mean%SD factor scores obtained on the Health Attitude Survey by men and women attending the medicine clinic
Men
(n$400)
Dissatisfaction with care 0.3750.18
Frustration with ill health 0.5650.26
High utilization of care 0.3250.20
Excessive health worry 0.3650.21
Psychological distress 0.4450.21
Discordant communication 0.3550.20
Note: NS4not significant.
474
with ill health, high utilization of care, and psychological
distress.
Table 3 shows correlations between factor scores and
variables for which information was available on the entire
population. As can be seen, no significant correlations with
age were observed. As might be expected, a strong nega-
tive correlation was observed between overall rating of
health (poor, fair, good, very good, or excellent) and the
frustration with ill health factor. Modest correlations be-
tween this overall rating and the remaining factors were
also observed.
The results were similar for somatic symptoms, as as-
sessed by the Patient Questionnaire of the PRIME-MD.
Here, strong positive correlations were observed between
the number of symptoms and the remaining factors. Also,
psychological symptoms, as measured by the Patient Ques-
tionnaire, showed a strong correlation with the psycholog-
ical distress factor, and modest correlations between psy-
chological symptoms and the other factors were seen.
Scores on the Illness Worry Scale showed rather high posi-
tive correlations with excessive illness worry and frustra-
tion with ill health, but the scores showed moderate-to-high
correlations with the remaining factors as well.
Correlations between factor scores and physician ratings
are also shown in Table 3. Those between doctor ratings of
severity of disease and all the factors were low, the highest
being with frustration with ill health (r40.20). Physician rat-
ings of somatization were modestly correlated with frustra-
tion with ill health and dissatisfaction with care, but were
relatively low with the remaining factors. Doctors’ ratings of
psychiatric history were, as might be expected, moderately
correlated with psychological distress. Significant but rela-
tively low correlations between physician-assessed psychi-
atric history and the remaining factors were observed. Phy-
sician enthusiasm about care was negatively correlated with
most factors at a low-to-moderate level.
Table 4 shows mean Health Attitude Survey factor
scores for the somatizing patients, a group of severely ill
Women
(n$610) t P
0.3850.18 10.53 NS
0.6050.24 12.76 0.01
0.3750.21 14.11 0.001
0.3850.22 11.04 NS
0.4950.21 13.89 0.001
0.3450.22 0.67 NS
Psychosomatics 40:6, November-December 1999
 Noyes et al.

patients, and nonsomatizing control subjects. The severely
ill patients had advanced cancer, heart failure, severe
chronic lung disease, etc., and on account of their advanced
disease, had been excluded from the somatizing and non-
somatizing groups. Table 4 also shows that the somatizing
patients had higher scores on dissatisfaction with care, frus-
tration with ill health, and psychological distress than the
severely ill patients, but both groups were comparable in
terms of utilization of care.
We examined the value of the Health Attitude Survey
for distinguishing somatizing and nonsomatizing patients.
Table 5 shows mean scores for these groups, together with
sensitivity and specificity, when cutoffs were used that
roughly balanced these statistics. We also estimated posi-
tive and negative predictive values for the primary care
setting based on the prevalence estimate of 24% by Kir-
mayer and Robbins.1 The eight-item subset apparently had
superior performance to the 27-item instrument. Note,
however, that this estimated performance may have been
optimistically biased due to the process of item selection.
Estimated sensitivities and specificities for other cutoffs are
shown on the ROC (receiver operating characteristic)
curves in Figure 1 and Figure 2.
DISCUSSION
Response to individual items of the Health Attitude Survey
distinguished the somatizing and nonsomatizing patients
attending a general medicine clinic. The somatizing pa-
tients not only perceived themselves as ill, but they also
were frustrated with the state of their health. They tended
to blame uncaring and ineffective physicians for unex-

TABLE 3. Correlations between factor scores on the Health Attitude Survey and age, ratings on the Patient Questionnaire of the
PRIME-MD, the Illness Worry Scale, and ratings by clinic physicians
Patient Questionnaire Physician Ratings
Rating Somatic Psychological Illness Severity of Physician Psychiatric
Age of Health Symptoms Symptoms Worry Illness Enthusiasm Somatization History
(n$1,010) (n$999) (n$1,009) (n$1,009) (n$1,009) (n$671) (n$670) (n$673) (n$671)
Dissatisfaction
with care 0.07* 10.44**** 0.037**** 0.32**** 0.43**** 0.07 10.26**** 0.34**** 0.18****
Frustration with
ill health 0.07* 10.62**** 0.58**** 0.43**** 0.53**** 0.20**** 10.30**** 0.41**** 0.26****
High utilization
of care 0.01 10.39**** 0.34**** 0.25**** 0.48**** 0.14*** 10.21**** 0.29**** 0.31****
Excessive health
worries 10.06 10.33**** 0.29**** 0.37**** 0.54**** 0.09* 10.14*** 0.23**** 0.18****
Psychological
distress 10.03 10.32**** 0.35**** 0.63**** 0.44**** 0.07 50.18**** 0.23**** 0.44****
Discordant
communication 0.30 10.30**** 0.27**** 0.37**** 0.39**** 0.18**** 10.17**** 0.20**** 0.28****

Note: PRIME1MD4Primary Care Evaluation of Mental Disorders.

*
P,0.05; **P,0.01; ***P,0.001; ****P,0.0001.

TABLE 4. Mean%SD factor scores for somatizing, severely ill, and control patients
A B C
Somatizing Severely Ill Control
(n$141) (n$109) (n$34)
Dissatisfaction with care 0.46950.169 0.36650.195 0.29050.156 A . (B, C)1
Frustration with health 0.70150.206 0.63750.218 0.46950.189 A.B.C
High utilization of care 0.42850.205 0.41850.238 0.33550.193
Excessive health worry 0.43150.241 0.38550.220 0.26250.157 (A, B) . C
Psychological distress 0.55550.206 0.45650.218 0.36950.204 A . (B, C)
Discordant communication 0.36950.227 0.38250.213 0.25550.172 (A, B) . C

1
All comparisons based on P40.05 after multiple comparisons correction via Tukey’s
standardized range test.

Psychosomatics 40:6, November-December 1999 475

Health Attitude Survey

TABLE 5. Screening performance of items from the Health Attitude Survey

Somatizing Control Positive Negative
Subjects Subjects Sensitivity Specificity Predictive Predictive
Items (n$141) (n$34) Cutoff1 % % % Value2 % Value2
27 53.4513.7 3
35.4512.1 $42 79 74 49 92
84 17.154.5 9.854.0 $14 78 88 67 93

1
Items scored 04strongly disagree, 14disagree, 24neutral, 34agree, 44strongly agree.
2
Based on a 24% prevalence of somatization as reported by Kirmayer and Robbins, 1991.1
3
Figures represent means5standard deviations.
4
See Table 1 for items.

FIGURE 1. ROC curve for 27-item Health Attitude Survey1

plained health problems. At least some reported distressing
worry about and preoccupation with health, and a propor-
tion reported more general psychological distress. In these
1 ways, somatizing patients appear to view themselves very
62
0.9 57
52
much as others view them and are able to communicate
47 this perception.26–28 This finding indicates that self-report
0.8 45
42 measures may be especially useful in evaluating these pa-
43
0.7
41 tients.
0.6 40
Our results suggest that the Health Attitude Survey is
Specificity

39
0.5 a valid measure of the attitudes and perceptions of soma-
37
0.4
tizing patients. In this study, evidence for external validity
came from several sources. For example, scores on various
0.3 32
subscales of the 27-item instrument were influenced in pre-
0.2 dicted directions by demographic and illness variables.
0.1 27 Also, the women rated themselves as having more psycho-
logical distress and as using more medical care.2 In addi-
0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 tion, scores on the Health Attitude Survey correlated mod-
Sensitivity erately with the number of somatic symptoms, as assessed
by the Patient Questionnaire of the PRIME-MD, another
indicator of somatization.40 Scores on this self-rated in-
FIGURE 2. ROC curve for 8-item screening subtest strument were also moderately correlated with ratings of
somatization made by clinic physicians. Finally, the so-
1
matizing patients scored higher than the nonsomatizing pa-
18 tients, and scores on the measure showed high predictive
17 14
0.9 16
15 value in identifying patients with somatization.
0.8 Our findings indicate that the Health Attitude Survey
13 is acceptable to patients. With a single exception, fewer
0.7
12 than 5% of the somatizing or nonsomatizing patients found
0.6
Specificity

the content of the questionnaire unimportant or upsetting

0.5 11 or had difficulty in choosing their answers. As might have
0.4 10 been expected, the somatizing patients tended to see the
0.3 9 content as more important than the control subjects. The
issue of acceptability seems important given the subject
0.2 8
6 matter involved. The patients revealed not only anxiety and
0.1 depressive symptoms but also hypochondriacal concerns,
0 all of which have negative connotations.7 In addition, the
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Sensitivity somatizing patients expressed the view that, not only were
their health problems unexplained, but also they had to deal

476 Psychosomatics 40:6, November-December 1999


with ineffective physicians, topics rarely discussed in the
health care setting.41
The Health Attitude Survey provides a multidimen-
sional assessment with which to evaluate somatization
within clinical populations and screen for somatizing pa-
tients. The instrument might be used to characterize various
patient groups according to the dimensions comprising the
scale. It might also be used to compare the level of so-
matization between or within groups over time. With re-
spect to screening, our post hoc analysis showed that eight
items from the Health Attitude Survey satisfactorily dis-
criminated between the somatizing and nonsomatizing pa-
tients. These items represented four of the six dimensions
and seemed to capture the core features of somatization.
Of course, a small number of items provides a highly ef-
ficient method for screening. For instance, before asking
patients whether each of a lengthy list of physical symp-
toms remains unexplained, one might learn nearly as much
from replies to a few self-administered questions.
Our data indicate that severe physical illness influ-
enced responses on the Health Attitude Survey. As can be
seen in Table 4, such illness produced higher scores on all
factors. However, even severely ill patients did not score
as high as the somatizing patients we studied. Thus, despite
being equivalent in their utilization of care, this severely
ill group reported less dissatisfaction with their health and
medical care and less psychological distress than the so-
matizing patients. Also, physician ratings of disease sever-
ity were weakly correlated with most factors, again sug-
gesting that the Health Attitude Survey is relatively
independent of documented physical disease. Nevertheless,
the effect of physical illness is an important concern for
instruments designed to identify or measure somatization,
including functional somatic symptoms and hypochondri-
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