Perspective

The Concept of Abnormal Illness Behavior

I. PILOWSKY

he concept of abnormal illness behavior’ was introduced in

1969 in an attempt to provide a framework for more constructive
study of conditions such as hysteria, hypochondriasis, conversion,
and functional overlay. Until that time, study of these conditions
had been problematic, as evidenced by the hysteria controversy of
the mid 19605.23 Issues of definition and classification will be
discussed first, followed by a description of some research in this
area.
Since abnormal illness behavior, or dysnosognosia, was first
introduced, it has not itself escaped controversy and was even
described as a dangerous idea at a conference of the European
Society for Psychosomatic Research in London in 1985 (Wolf
HH, personal communication, 1985). It is indeed gratifying that
abnormal illness behavior has been recognized as dangerous be-
cause its formulation was, to a considerable extent, intended to
make quite explicit just how dangerous diagnoses such as hypo-
chondriasis, hysteria, and psychogenic pain were, and hopefully,
to point to ways in which any such danger could be eliminated, or
at least minimized.
Previously I have defined abnormal illness behavior as

the persistence of a maladaptive mode of experiencing, perceiving,

evaluating, and responding to one’s own health status, despite the
fact that a doctor has provided a lucid and accurate appraisal of the
situation and management to be followed (if any), with opportuni-
ties for discussion, negotiation, and clarification, based on adequate
assessment of all relevant biological, psychological, social, and
cultural factors.4

This definition grew out of the concept of illness behavior

introduced by Mechanic and Volkart,5 which facilitated the adop-
tion on one hand of a more sociological and, on the other hand, a
more operational approach to clinical concepts, such as hypochon-
Received April 17. 1989; revised
driasis, hysteria, and, more recently, the somatoform disorders
June 15, 1989: accepted July 20, 1989.
described in DSM-111,6 DSM-1II-R,7 and the proposed new draft of From the Department of Psychiatry.
Chapter 10 of lCD-JO on mental, behavioral and developmental University of Adelaide, Adelaide, South
disorders.8 Australia. Address reprint requests to
Dr. Pilowsky, Royal Adelaide Hospital,
The usefulness of the sociological perspective soon emerges
Adelaide, South Australia 5001.
on close examination of the criteria for diagnosing hypochondri- Copyright © 1990 The Academy
asis as enumerated in DSM-III-R. The chief criteria are preoccu- of Psychosomatic Medicine.

VOLUME 31 NUMBER
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Abnormal Illness Behavior

pation with the fear of having, or the belief that it should be based, and the mode of its communi-
one has, a serious disease, based on the person’s cation are not clearly defined. The “danger” re-
interpretation of physical signs or sensations as ferred to above, can now be seen to reside in the
evidence of physical illness; appropriate physical fact that a doctor has to be depended upon to be
evaluation that does not support the diagnosis of “right” and to give an opinion in an “adequate”
any physical disorder that can account for the manner. Many would feel that on such a basis, it
physical signs or sensations or the person’s un- is virtually impossible to make the diagnosis
warranted interpretation of them and the symp- unless the patient is virtually delusional. And
toms are not just symptoms of panic attacks; and indeed, this may be why some doctors never
the persistent fear of having, or belief that one record such a diagnosis.9
has, a disease despite medical reassurance to the On the other hand, it should be understood
contrary. that the doctor referred to in the definition is an
Anyone who has studied hypochondriasis ideal type. In practice, the patient described
will readily acknowledge that the last criterion is would not accept reassurance from any number
one of the most problematic criteria, since clearly of doctors. In this regard, it is interesting to com-
the nature of the reassurance, the data on which pare the doctor-patient relationship and the witch

TABLE 1. Outline of somatically focused abnormal TABLE 2. Outline of psychologically focused

illness behaviors abnormal illness behaviors

A. Illness Affirming A. Illness Affirming

Motivation predominantly conscious Motivation predominantly conscious

1. Malingering I. Malingering
2. Chronic factitious syndrome with physical 2. Factitious disorder with psychological symptoms
symptoms (Munchausen’s syndrome) (Ganser syndrome)
3. Factitious disorder with physical symptoms Motivation predominantly unconscious
Motivation predominantly unconscious 1. Neurotic
I. Neurotic (somatoform disorders) a. “Psychic hypochondriasis”
a. Somatization disorder b. “Phrenophobia”
b. Conversion disorder c. Dissociative reactions
c. Psychogenic pain disorder d. Psychogenic amnesia
d. Hypochondria.sis 2. Psychotic
2. Psychotic Delusions of memory loss or loss of brain
a. Hypochondriacal delusions associated with function
I. Major depressive disorder with mood- B. Illness Denying
congruent psychotic features
Motivation predominantly conscious
2. Schizophrenic disorder
1. Denial of psychotic symptomatology to avoid
3. Monosymptomatic hypochondriacal psychoses
stigma, hospital admission, or to gain discharge
B. Illness Denying from care
Motivation predominantly conscious 2. Denial of psychotic illness to avoid perceived
1. Denial to obtain employment discrimination by health care professionals or
2. Denial to avoid feared therapies employers
3. Denial of illness (e.g., VD) due to shame and guilt Motivation predominantly unconscious
Motivation predominantly unconscious 1. Neurotic: refusal to accept “psychological” diag-
I. Neurotic nsis or treatment in the presence of neurotic
a. Noncompliance following myocardial infarction illness, personality disorder or dependency
b. Counterphobic behavior in hemophilia syndromes (alcohol, opiates, etc.)
c. Noncompliance with antihypertensive therapy 2. Psychotic: denial of illness (‘lack of insight’) in
2. Psychotic psychotic depression, manic states, and
Denial of somatic pathology, e.g., as pan of schizophrenia
hypomanic or schizophrenic disorder 3. Neuropsychiatric: confabulatory reaction in
Korsakoff’s psychosis and other organic brain
Neuropsychiatric
Anosognosia syndromes

208 PSYCHOSOMATICS
 Pilowsky

doctor- (or diviner-) patient relationship seen in other writers. However, an examination of the
Zulu culture.’#{176}In the latter case, the healer takes literature reveals that this entity has never been
a history by making statements to which the truly defined in the past, but rather was a phantom
patient is required to answer “I agree” or to clap concept occasionally glimpsed behind and be-
hands; the diviner decides whether agreement is tween terms such as “sick role,” “illness behav-
indicated. Further, the diviner does not make a ior,” “sickness,” and “disease.” Anyone who has
diagnosis, but conveys a message from the ances- worked in the field of workers’ compensation
tors in which they indicate how they have been soon becomes aware that illness or disability can
offended. She also advises the sufferer on how to be seen as a “property” of an organism that can
expiate the offense. In such a situation, hypo- be traded for money in one marketplace and for
chondriasis or abnormal illness behavior cannot health care in another. It is obvious, however, that
arise, since the syndromes are dependent upon an illness always costs somebody something,
the existence of a healing profession that claims whether it is cashed in for “sick role units” or
and is granted special authority by a society and “money.”
offers the benefits of its own knowledge and If we think of illness in this way, it has both
treatments. heuristic and practical value as an anchoring con-
The purpose of the definition of abnormal cept. Its practical value lies in its usefulness to
illness behavior, therefore, was to make these clinicians who, in any sociocultural setting, must
issues more explicit and also to fashion a bridge establish what is regarded as an illness so that
between the sociocultural and the psychopatho- decisions can be made about recommendations
logical factors that operate so strikingly on the for sick leave, invalid pensions, compensation,
process of making diagnoses such as hypochon- and so forth.
driasis. Furthermore, it was intended to remind Its heuristic value rests in its offering a cri-
nonclinicians that some forms of discord be- terion for distinguishing between illness and non-
tween doctors and patients had their origins in the illness in any society or culture. And, since this
patients’ psychopathology rather than in any criterion depends heavily on the sick role con-
other factor. cept, which requires the patient to cooperate with
The major sociological issue was seen to be a doctor in an effort to regain health and divest
that of admission to the sick role” and the vali- himself of the sick role, it emphasizes the central
dation of symptoms and discomfort as evidence function of the doctor in this process, and his need
of an “illness.” In a paper that was published in to understand the social and cultural forces that
1978 on classification of abnormal illness behav- play on him and his patients. Furthermore, if this
iors,’2 the concept was extended to include denial definition of illness is accepted, we can speak
of illness and to cover both somatic and psycho- more confidently of “illness experiences,” “ill-
logical focusing. Tables 1 and 2 outline somati- ness cognitions,” “illness behaviors,” “illness ex-
cally and psychologically focused abnormal ill- planatory models,” and so on, knowing to what
ness behaviors. “illness” refers.
In addition, the term illness was defined, to Disease, on the other hand, can be defined as
fill a gap in previous conceptualizations, as “an a constellation of “public” data that experts rec-
organismic state which fulfills the requirements ognized by society regard as evidence of an “ill-
of a relevant reference group for admission to the ness” whether or not it is recognized as such by
sick role.” This definition is based on the propo- society at large. Thus, a condition such as hypo-
sition that illness is most usefully viewed as a chondriasis presents a distinct and unusual clini-
currency in the health care marketplace where cal problem since it involves a patient who
values are set by society and exchanges are reg- disagrees with his doctor’s opinion of his health
ulated to a considerable degree by doctors. It is status, and, on that basis, earns a diagnosis! But,
readily conceded that this definition of illness is of course, disagreement is not sufficient. It is also
somewhat idiosyncratic compared with those of necessary that the patient show a pattern of think-

VOLUME 31 ‘NUMBER 2’SPRING 1990 209

Abnormal Illness Behavior

ing, feeling, and behavior regarded as psycho- CATEGORIES OF ABNORMAL

pathological. ILLNESS BEHAVIOR
To describe a clear case, the patient might be
convinced that he has cancer despite reassurance Thus far, we have discussed abnormal illness
to the contrary by one or more doctors. Further, behavior in categorical terms-the patient either
the patient should be absolutely certain and dog- has it or does not have it. For certain purposes,
matic, whereas the doctor should only be “rea- this approach is obviously appropriate, e.g., when
sonably” sure. The patient should not be prepared we wish to establish diagnosis on the basis of
to negotiate, while the doctor should be, and, agreed criteria. In practice, however, there are
most important, the patient should deny or stren- illness behaviors that, while not typical, are not
uously resist the idea that non-organic, i.e., psy- abnormal either. It is useful, therefore, to think of
chological and environmental, factors play any illness behaviors as “normal” or “anomalous”
part in his illness. This latter criterion is of par- and then to subdivide the anomalous behavior
ticular importance, since it requires the doctor not into atypical, abnormal, and malingering.
simply to inform the patient that his fears are The term “anomalous” is used here to mdi-
unfounded but also to provide a complete psy- cate a stage at which an illness behavior is re-
chobiological appraisal in terms that are appro- garded as being unusual or discordant. It suggests
priate and readily understood. the possibility of, for example, a somatoform
Although DSM-lll-R does not include this disorder, but has not been sufficiently explored
requirement in its description of somatoform dis- to be described as atypical or abnormal. In other
orders, the lCD-JO draft states, words, this is the stage when a provisional or
tentative diagnosis may be made.
Even when the onset and continuation of the The term “atypical” conveys the type of
[physical] symptoms bear a close relationship illness behavior Lhat is more likely to reflect a
with unpleasant life events or with difficulties
personality or socioculturally determined style
or conflicts, the patient usually resists attempts
to discuss the possibility of psychological cau- rather than a psychopathological entity. A good
sation: this may be so in the presence of obvious example is the compulsive personality who de-
depressive and anxiety symptoms.9 scribes his illness with much circumstantiality
but, ultimately, comes to the point. The term
The upshot, therefore, is that before making atypical also points up the dearth of information
a definitive decision that a patient is manifesting available concerning typical illness behaviors in
abnormal illness behavior of a particular type, it the general range of patients with or without
is necessary to proceed through a thorough clin- somatic pathologies. If the term is used, it implies
ical assessment that takes into account somatic, that in a particular instance the usual spectrum of
emotional, behavioral, and sociocultural issues. illness behaviors has been established, or that the
If this is done, many patients will readily change behavior is atypical for the particular individual
their view of their health status and move closer being assessed.
to that of their medical adviser. Experienced cli- Malingering, which is seen most commonly
nicians know full well that patients seen in liaison in military and prison populations, is mentioned
services are often perfectly prepared to acknowl- for the sake of completeness, although, since by
edge the relevance of psychosocial issues to their definition the motivation is completely conscious
illness (particularly when a clear somatic illness and directed at a specific purpose, it cannot be
is present and acknowledged). In the case of accorded the sick role in the ordinary sense, as is
somatoform disorders, however, it becomes clear usually the case with abnormal illness behavior.
that the insistence on a somatic view of the con- What is probably true, however, is that abnormal
dition is not an “error” but indeed a defense for illness behaviors of the disease-affirming type
avoiding painful issues and maintaining psycho- evoke particular concern from doctors because of
logical equilibrium. the fear that malingering may be present.

210 PSYCHOSOMATICS

1I& A
 Pilowsky

The general classification of abnormal ill- clinic patients were also more likely to report
ness behavior mentioned earlier, grouped condi- constant awareness of symptoms. Recently,
tions, syndromes, or behavioral constellations as Wessely and Powell’4 have shown that patients
they had been described in the literature. Not all with chronic fatigue syndrome could be distin-
of these manifestations of abnormal illness be- guished from those with depression only by their
havior are regarded as “psychiatric disorders” in view of the origin of their symptoms.
the sense that they have been included in classi- Overall, of course, the categorical approach
fications such as DSM-lll-R or ICD-9. However, has its problems, especially if case note surveys
they are recognizable clinical syndromes that are involved. Beaber and Rodney’s findings9 at
may be included at some future date, depending UCLA demonstrate this very well. In a series of
on the various influences that decide such mat- family practice patients, not one was diagnosed
ters. (Consider the examples of homosexuality as suffering from hypochondriasis or any related
and alcoholism.) Perhaps the ultimate sign that a condition, even though their scores on the
condition has achieved societal recognition as an Whiteley Index of Hypochondriasis’5 indicated
“illness” is that it is accepted by the courts as that such problems were present in certain pa-
compensable. tients.
Turning to the dimensional research ap-
RESEARCH FINDINGS proach, we find the use of questionnaire mea-
sures that seek to quantify the various elements
Turning from the issues of definition and classi- of a patient’s illness, attitudes, and beliefs. Per-
fication, we may now consider some of the ways haps one of the first of these (which was not a
in which abnormal illness behavior has been re- symptom inventory like the Minnesota Multipha-
searched and, briefly, some findings. sic Personality Inventory HS scale) was the 14-
The two major approaches have been the item Whiteley Index of Hypochondriasis,’5
categorical and the dimensional, with biological which was later expanded to become what is now
or psychosocial measures as the dependent vari- the 62-item Illness Behavior Questionnaire
ables. Where abnormal illness behavior has been (IBQ).’6 The IBQ generates scores on seven fac-
viewed in categorical terms, patients diagnosed tor analytically derived scales, two second order
as hypochondriacal or hysterical have been in- scales, and a discriminant function. It has been
vestigated using diagnoses arrived at in a variety applied in a variety of studies as an aid to clinical
of ways, making comparisons difficult. How- assessment and as a source of items for new
ever, in recent years, attention has focused on scales, e.g., the Somatic Symptom Recognition
what DSM-lll-R describes as somatoform pain Scale.’7 It has found a particular place in the
disorders, usually seen in the context of multidis- assessment of somatoform disorders, especially
ciplinary pain management centers. the somatoform pain disorders.’8
Apart from the use of diagnostic criteria, The seven scales of the IBQ reflect the major
structured interview schedules, such as the Ill- elements of illness behavior that need to be taken
ness Behavior Assessment Schedule,’3 have also into account in any patient evaluation. Scale 1,
been used. This schedule seeks to establish the General Hypochondriasis, taps fearfulness about
various elements of the patients’ beliefs and atti- illness and a phobic attitude. Psychiatric patients
tudes concerning their health status. In a study are high scorers on this scale, while pain clinic
comparing 49 pain clinic patients with 32 rheu- patients achieve only low scores. Scale 2, Disease
matology patients, certain findings illustrate Conviction, assesses a tendency to be convinced
quite well the defensive function of somatization. that somatic pathology is present and a resistance
For example, when the presence of dysphoria to reassurance. This scale tends to distinguish
was acknowledged, it was attributed more often pain clinic patients from all other groups.’9 It also
to psychological stresses by rheumatology clinic predicts general practice utilization, especially in
patients than pain clinic patients (p<Ol). Pain men with pathology.20 The presence or absence

VOLUME 31’NUMBER 2 SPRING

#{149} 1990 211

L
 Abnormal Illness Behavior

of pathology alone does not predict utilization. view of the literature. In our department, we
Scale 3, Psychological Versus Somatic Fo- carried out a pilot study22 on pain patients, using
cusing, is a bipolar scale. A high score indicates IBQ scales to group them into high, medium, and
acceptance of a psychological perspective, and a low conversion categories. Those in the high-
low score indicates somatization and rejection of conversion group denied any emotional distur-
a psychological view. Pain clinic patients are low bance and attributed all problems to their illness.
scorers and psychiatric patients are high scorers The medium-conversion group acknowledged
on this scale. Scales 4 (Affective Inhibition) and dysphoria but attributed it to their illness, and the
5 (Affective Disturbance) measure aspects of low-conversion group reported dysphoria and at-
affect. Scale 4 measures a tendency to inhibit tributed it to life stresses. Using a loud tone as a
feelings and to not communicate them. Scale 5 stimulus, we found greatest arousal in the low-
measures anxiety and depression. Scale 6 (De- conversion group; low arousal occurred in the
nial) taps the tendency to attribute difficulties to high-conversion group and the medium-conver-
illness and to deny current life stresses. (Of sion group. We wondered whether the latter
course, a low score indicates the opposite.) Fi- group’s illness behavior was best suited to man-
nally, Scale 7 (Irritability) taps interpersonal fric- aging the doctor-patient relationship, i.e., by ac-
tion. knowledging affect but attributing it to a somatic
The second order factors are Disease Affir- illness.
mation, which combines Disease Conviction and All that has been said about abnormal illness
Psychological Versus Somatic Focusing, and behavior has serious implications for the clinical
Affective State, which combines General Hypo- professions and especially for physicians. The
chondriasis, Affective Disturbance, and Irrita- hypochondriacal patient challenges the most fun-
bility. damental assumptions that we hold as doctors
The discriminant function derives from a about our knowledge, professional behavior, and
comparison of general practice and pain clinic adequacy. Little wonder that such patients have
patients. The formula is DF=53.8+5.7(DC)-l0.2 affronted, repelled, and alarmed physicians for
(PvS)-0.6(AI)+2.4(D). A high score indicates a centuries. However, as professionals, we would
#{149} pattern similar to that shown by pain clinic pa- do better to learn from the lessons they offer us
tients the majority of whom showed a somato- and, in particular, apply them to our activities as
form pain disorder. (A second form of the IBQ, medical educators.
Form B, does not assume the presence of illness.) In this regard it seems to me that a concept
It is readily apparent that the IBQ may be such as abnormal illness behavior can play a
applied in a variety of ways to the elucidation of pivotal role as a way of conveying the inescap-
illness behaviors. Combined with careful inter- able clinical necessity for physicians to take into
viewing, it should help us establish the affects, account the psychosocial, as well as the biologi-
attitudes, beliefs, cognitions, and behaviors asso- cal, aspects of patients’ difficulties. It is particu-
ciated with illness. The description of these may larly important that students grasp the need to
be a far more informative and acceptable way of assess illness behavior not only on the basis of the
describing a patient’s clinical state than the terms doctor’s notions of what is “normal,” but also on
abnormal illness behaviors or somatoform disor- the patient’s subjective experiences, including
ders. / attributions and emotions.
The significance of these for the course of That this is often not the case is suggested by
illness will involve psychophysiological studies, the findings of Jones et al.23 that physicians’
treatment evaluations, outcome studies, and interpretations of patients’ illness behaviors do
many other approaches, some of which have al- not take their subjective state into account. Stu-
ready begun. For example, Lang et al.2’ have dents need to understand that the diagnosis of
shown the ways in which cognition may alter abnormal illness behavior or somatoform disor-
physiology, and they also provide a useful over- der is a difficult task and a heavy responsibility.

212 PSYCHOSOMATICS

-
 Pilowsky

If they understand this concept properly, they This article is based on a paper presented at
will be equipped to practice the kind of doctoring the annual meeting of the American Psychoso-
that benefits all their patients, whatever their matic Society, held March 9-11, 1989, in San
diagnosis. Francisco.

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