International Review of Psychiatry, February 2013; 25(1): 5–18

Somatic symptom disorders and illness behaviour: Current perspectives

KIRSTY N. PRIOR & MALCOLM J. BOND

School of Medicine, Flinders University, Adelaide, South Australia, Australia

Abstract
The behavioural aspects of somatic symptom disorders have received minimal research attention to date. The first section
of this paper identifies key theoretical perspectives relevant to behavioural responses to illness. Specifically, the sociological
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concept of illness behaviour is offered as a general framework in which to consider the range of psychosocial factors asso-
ciated with responses to perceived illness. Further, the potential relevance of the construct of abnormal illness behaviour
and the cognitive behavioural conceptualization of health anxiety is explored. The second part of the paper describes
various approaches to the operationalization of illness behaviour, with particular emphasis on the Illness Behaviour
Questionnaire, an instrument with a rich history of application. Additional insight is provided into two contemporary
instruments which aim to measure overt behavioural aspects of illness more specifically. The third and final section of the
paper makes recommendations for how future research may advance the understanding of state- versus trait-based
characteristics of illness behaviour. Suggestions are made for how adaptive forms of behaviour (e.g. self-management,
appropriate coping) may reduce the risk of developing a somatic symptom disorder or alternatively, minimizing the
potentially negative psychosocial implications of such a presentation.
For personal use only.

Introduction and seeks to operationalize the psychological con-

comitants of somatic symptom disorders (Martin &
Although the field of psychosomatic medicine empha-
Rief, 2011).While there has been considerable empha-
sized the ‘psychological’ component of physical ill-
sis on cognitive (e.g. attributional style, catastroph-
ness by generating largely psychological explanations
izing) and affective (e.g. emotional distress, negative
during the early to mid twentieth century (Fava &
affect) aspects of such presentations, there is a poor
Sonino, 2000; Sharpe & Carson, 2001), later con-
understanding of their behavioural manifestations.
ceptualizations have instead regarded illness as the
The purpose of this paper is to review the range
manifestation of a complex interplay of biomedical
of theoretical perspectives which may contribute to
and psychosocial factors, in keeping with a contem-
an understanding of how somatic symptom disorders
porary biopsychosocial framework (Fava & Sonino,
may manifest behaviourally. Notably, there is recog-
2000; Lyons & Chamberlain, 2006).
nition that particular behaviours may predispose to
As described elsewhere (e.g. Dimsdale & Creed,
the development of somatic symptom disorders, or
2009; Martin & Rief, 2011), there have been con-
conversely, reflect consequences of these presenta-
certed efforts in recent years to revise the chapter on
tions (Rief & Broadbent, 2007). The key instruments
somatoform disorders in the Diagnostic and Statistical
used to measure illness behaviour are reviewed and
Manual of Mental Disorders, fourth edition, text revi-
shortcomings of the existing literature are identified,
sion (DSM-IV-TR) (APA, 2000) in readiness for the
with specific suggestions as to how research could
publication of DSM-5. The alternative label of
advance the current conceptualizations of somatic
‘somatic symptom disorders’ has been offered to
symptom disorders. The main clinical implications
characterize more precisely the range of presentations
are also discussed.
subsumed under this overarching label to improve the
utility of this classification tool and better reflect the
presentations observed typically in clinical practice
Conceptualizations of illness behaviour
(Dimsdale & Creed, 2009). Notably, the revised clas-
sification removes any reference to symptoms as The extent to which people perceive physical illness
‘medically unexplained’ (Dimsdale & Creed, 2009) and are attuned to variations in the appearance or

Correspondence: Dr Malcolm J. Bond, Discipline of General Practice, School of Medicine, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia.
Tel: ⫹ 61 8 7221 8503. Fax: ⫹ 61 8 7221 8544. E-mail: malcolm.bond@flinders.edu.au

(Received 15 August 2012; accepted 14 September 2012)

ISSN 0954–0261 print/ISSN 1369–1627 online © 2013 Institute of Psychiatry
DOI: 10.3109/09540261.2012.732043
 6 K. N. Prior & M. J. Bond
functioning of their bodies has a long history of
empirical investigation. Traditionally there has been
particular interest in responses regarded as excessive
or maladaptive based on the illness circumstances or
available somatic information. Along with terms
such as somatization and hypochondriasis, alterna-
tive theoretical constructs have received labels such
as subjective health complaints, medically unex-
plained symptoms and functional symptoms/syn-
dromes (Duddu et al., 2006; Kirmayer & Looper,
2006; Mayou et al., 2005). Despite the common
theme of perceived physical illness without corre-
sponding biomedical abnormality, the specific
approaches to the definition and measurement of
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these constructs partly reflect the historical context
and theoretical perspectives (e.g. psychiatric, medi-
cal, psychological, cognitive behavioural and physi-
ological) that have informed their development.
Illness behaviour
Illness behaviour is a sociological concept which
places primary emphasis on illness responses at the
individual level (Mechanic, 1962, 1977, 1982, 1986a;
Mechanic & Volkart, 1960). Illness behaviour refers
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to the types of responses individuals manifest to
bodily information (Mechanic, 1986a). Specifically,
illness behaviour encompasses the variety of ways in
which individuals examine their bodies for possible
abnormalities, construe somatic stimuli, employ
strategies to deal with perceived symptoms and
engage both formal and informal sources of interven-
tion (Mechanic, 1986a, 1986b). The manner in
which people interpret and respond to illness has
implications for both the illness experience (i.e.
whether or not the person receives appropriate med-
ical care and his/her level of cooperation), and the
individual’s lifestyle (i.e. interference with day-to-day
activities (Mechanic, 1986b)).
Mechanic and Volkart (1960) noted considerable
individual differences in behavioural responses to
symptoms. While somatic sensations are experienced
commonly, relatively few receive medical attention
(Mechanic, 1978b). Many sensations are considered
sufficiently minor that they are either endured or
ignored. Yet other people may seek medical opinion
and relief from societal obligations upon the slightest
indication of abnormality (Mechanic, 1962, 1977;
Mechanic & Volkart, 1960). These individual differ-
ences in illness behaviour may not be simply indica-
tive of underlying biomedical activity (Mechanic,
1986b). Symptoms which share similar objective
characteristics may elicit different forms of illness
behaviour. For some, a relatively minor medical
condition may trigger such distress that it has
adverse implications for psychosocial functioning
(Mechanic, 1978b). Conversely, a serious condition
may generate little attention and minimal interference
with functioning.
Illness behaviour reflects a dynamic process in
which responses change according to personal and
social needs (Mechanic, 1977). Variations in illness
behaviour have been attributed to factors such as
past illness history, sensitivity to, and tolerance of,
physiological information (e.g. pain), coping compe-
tency and social interpretations of illness (Mechanic,
1977, 1986a). Mechanic (1986a) suggests that ill-
ness may even facilitate the attainment of personal
goals in the workplace, at home or socially. High-
lighting obvious conceptual overlap with the sick role
(Parsons, 1951), the motivation to ‘become sick’ and
seek medical care may be initiated by the wish for
relief from societal responsibilities and other lifestyle
pressures (Mechanic, 1977, 1986a). Illness may even
serve as justification for inability to fulfil societal
obligations. Further, attention from doctors may
provide valuable social support to individuals for
whom such support is not readily available elsewhere
(Mechanic, 1986b).
Alternatively, illness behaviour may reflect dispo-
sitional tendencies to behave in a certain way (i.e. a
relatively stable response pattern). For example,
some people respond to any perceived abnormality
with emotional distress, seeking medical advice
readily. Those with a higher level of introspection
experience poorer physical and psychological well-
being, perceive more adverse effects of stressful life
events and have a higher utilization of healthcare
services (Mechanic, 1979, 1980, 1986a). They are
also more likely to construe benign, commonly
experienced somatic events as physical abnormality
(Mechanic, 1986a).
Seeking medical care represents the outcome of
perceptual, cognitive, attributional and decision-
making processes (Mechanic, 1986a, 1986b). How-
ever, the clinician plays an important role in
encouraging adaptive forms of illness behaviour and
ignoring inappropriate responses (Mechanic, 1977,
1986b). Responses to illness may be shaped by
sociocultural influences such as sex role expecta-
tions and culture-specific beliefs and values
(Mechanic, 1976, 1977). Social learning underpins
the development and maintenance of many illness
responses, with the values and beliefs characteristic
of a particular cultural group having an influence on
the descriptive terms used for symptoms. While
many cultures encourage open discussion of somatic
information and regard medical care-seeking as an
appropriate response, others prefer stoicism and
denial of symptoms (Mechanic, 1986b). Some cul-
tural groups are less accommodating of psychologi-
cal attributions for illness (Mechanic, 1982), with a
greater inclination to report physical rather than
psychological symptoms.

Importantly, illness responses are influenced by
the perceived seriousness of the presenting symp-
toms and the degree of interference with day-to-day
activities (Mechanic, 1982). Knowledge about ill-
ness, along with tolerance of physical symptoms such
as pain (Mechanic, 1986b, 1978b), are likely to influ-
ence perceived seriousness and the steps required to
cope with symptoms (Mechanic, 1986b). However,
the perceived salience of symptoms is not necessarily
compatible with a medical evaluation (Mechanic,
1976, 1978b).
Professional advice is more likely to be sought
when symptoms are perceived as new and unusual,
elicit a sense of fear, and a logical explanation is not
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readily available (Mechanic, 1976). Unsuccessful
attempts to attribute symptoms to ‘normal’ (i.e. com-
monly experienced, innocuous) somatic occurrences
also often lead to medical opinion being sought, with
medical consultation representing a socially accept-
able means of dealing with ambiguity (Mechanic,
1978b, 1986b). Individuals are more likely to respond
to symptoms that occur regularly and are evident to
other people as well (Mechanic, 1982).
Physical symptoms may mask underlying psycho-
logical distress that actually prompted the person to
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seek medical advice (Mechanic, 1976, 1977, 1978a,
1986b). Moreover, it may be difficult to distinguish
between symptoms (e.g. sleep difficulties, fatigue,
aches, loss of appetite) indicative of a highly stressed
state or a specific biomedical abnormality (Mechanic,
1976, 1977). Not surprisingly, extensive medical
investigation and surgical procedures are more com-
mon among those with ambiguous symptoms
(Mechanic, 1976). There is often the need for med-
ical practitioners to undertake a comprehensive
work-up of the presenting symptoms to explore the
possibility of genuine pathology.
Abnormal illness behaviour
One approach to the conceptualization and opera-
tionalization of response to illness is abnormal illness
behaviour (AIB) (Pilowsky, 1969, 1997). Pilowsky’s
(1969) investigations of clinical conditions such as
hypochondria and hysteria led to his suggestion that
these psychosomatic disorders represent abnormal
forms of illness behaviour (Pilowsky, 1994). Pilowsky
acknowledged the relevance of Parsons’s (1951) sick
role model to the understanding of these presenta-
tions, particularly the important role played by med-
ical practitioners in granting admission to the sick
role. The original conceptualization of AIB centred on
patient–doctor disagreement (Pilowsky, 1969). That
is, AIB is usually suspected when self-reported somatic
symptoms are not accompanied by a corresponding
degree of biomedical abnormality (Pilowsky, 1978),
indicating that the individual has inappropriately
Illness behaviour 7
either sought admission or been admitted to the sick
role (Pilowsky, 1986b). As part of the assessment of
AIB, Pilowsky (1990) emphasized the importance of
examining cognitive and affective states, along with
overt behaviour, to establish whether they are indeed
inappropriate, rather than characteristic of a specific
disease (Waddell et al., 1989). Generally, the degree
to which AIB is evident is reflected in the ways indi-
viduals react to medical advice (e.g. level of coopera-
tion with advice and treatment; Pilowsky, 1986b) and
their satisfaction with the medical interpretation of
their symptoms. Those who reject the explanation
may continue to make demands of the medical prac-
titioner (Pilowsky, 1978).
Research has focused predominantly on the
somatic affirmation of illness (e.g. hypochondriasis)
disproportionate to pathology (Pilowsky, 1986b,
1997). For example, the diagnosis of hypochondria-
sis is conceptualized as disease preoccupation that
endures despite medical reassurance (Pilowsky,
1994). Individuals with AIB often refute the sugges-
tion that psychological factors may influence their
physical health (Pilowsky, 1997).
To acknowledge the potential for the construct
(and indeed label) of AIB to be used inappropriately
(Pilowsky, 1986a), the definition of AIB assumes the
availability of an accurate and logical medical inter-
pretation of presenting symptoms along with suitable
management recommendations (Pilowsky, 1994).
That is, even though some individuals may be inclined
to express views considered to be maladaptive, their
responses may actually be relatively appropriate given
the nature of their illness (Mayou, 1989).
While a clinician may advise that all reasonable
steps have been taken to eliminate the possibility of
illness, a person who behaves in a manner consistent
with AIB would be expected to vigorously challenge
such an evaluation and be unwilling to consider pos-
sible alternative explanations for symptoms (Pilowsky,
1990). Moreover, rejection of the contribution of
psychological or environmental factors to the illness
experience would be expected (Pilowsky, 1990).
Medical practitioners who gain insight into concom-
itant life issues may be in a better position to help
modify health perceptions and ultimately encourage
realistic interpretations more compatible with those
of the health professional.
Contexts to which AIB is relevant
AIB has been examined in diverse illness and socio-
cultural contexts but, traditionally, among individu-
als with chronic pain (Keefe et al., 1986; Large &
Mullins, 1981; Main & Waddell, 1987; Pilowsky,
1993; Pilowsky & Katsikitis, 1994; Pilowsky et al.,
1979; Pilowsky & Spence, 1975, 1976, 1994; Sikorski
et al., 1996; Toomey et al., 1984; Waddell et al., 1989;
 8 K. N. Prior & M. J. Bond
Zonderman et al., 1985). In the psychiatric domain,
AIB has helped to understand the situation of people
with somatoform disorders including somatization
disorder, conversion disorder, hypochondriasis and
body dysmorphic disorder (Chaturvedi et al., 2006).
There is evidence of illness-affirming AIB among
individuals with somatic symptoms attending inpa-
tient psychiatric clinics (Pilowsky, 1993; Wise et al.,
1990) and receiving outpatient care (Boyle & Le
Déan, 2000; Chaturvedi & Bhandari, 1989;
Chaturvedi et al., 1996; Guo et al., 2000; Wise et al.,
1990).
There has been some exploration of the extent to
which AIB is relevant to people with diagnosed med-
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ical conditions for which there is documented bio-
medical abnormality. A wide variety of illness groups
has been examined, although such studies often rep-
resent isolated applications of the IBQ to a particular
illness. Specific illustrative conditions for which AIB
has been examined include myocardial infarction
(Byrne, 1984; Byrne & Whyte, 1978, 1979; Pruneti
et al., 1993), rheumatoid arthritis and osteoarthritis
(Ahern et al., 1995; McFarlane et al., 1987; Murphy
et al., 1988; Prior & Bond, 2004), Ménière’s disease
(Savastano et al., 1996), tinnitus (Rizzardo et al.,
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1998; Savastano & Maron, 1999), tension and
migraine headaches (Demjen & Bakal, 1981; Wise
et al., 1994), multiple sclerosis (Trigwell et al., 1995),
epilepsy (Lykouras et al., 2006; Stone et al., 2004),
gastrointestinal disorders such as ulcerative colitis
(Miller et al., 2001) and Crohn’s disease (Hobbis
et al., 2003), and cancer (Grassi & Rosti, 1996a,
1996b; Porcelli et al., 2007).
AIB has also been examined in the general practice
setting (Pilowsky et al., 1987; Scicchitano et al.,
1996), with comparisons typically made between the
responses of general practice and pain clinic patients
(Pilowsky & Spence, 1983, 1994). Other researchers
have continued Pilowsky and Spence’s (1983, 1994)
examination of AIB among general practice popula-
tions (Guo et al., 2002), even though such investiga-
tions may arguably involve varying combinations of
physical and psychosocial issues in the presenting
complaints.
AIB has also featured in a modest number of stud-
ies of conditions for which a definitive diagnosis and
prognosis are equivocal, such as chronic fatigue syn-
drome (CFS) (Hickie et al., 1990; Schweitzer et al.,
1994; Trigwell et al., 1995; Wilson et al., 1994), fibro-
myalgia (Birnie et al., 1991; Ercolani et al., 1994;
Robbins et al., 1990), and bowel disorders such as
irritable bowel syndrome (Hobbis et al., 2003; Miller
et al., 2001) and chronic idiopathic constipation
(Chattat et al., 1997; Hobbis et al., 2003). Hobbis
et al. (2003) found that levels of AIB did not differ
between individuals with either chronic, idiopathic
constipation or irritable bowel syndrome (IBS) and
those with Crohn’s disease. However, all of these
clinical groups had higher levels of illness-affirming
AIB and associated psychological distress than the
control group of ‘wellness’ clinic patients (Hobbis
et al., 2003).
Health anxiety
An alternative conceptualization of illness behaviour
is illustrated by the literature on excessive health con-
cern (e.g. health anxiety, hypochondriasis). Salkovs-
kis and Warwick (2001) contend that people with
health anxiety misconstrue bodily sensations and
variations (e.g. altered bodily functions, unusual skin
markings, structural irregularities, etc.) and even
general health information (e.g. medical advice and/
or recommendations, information conveyed within
the mass media, and results of medical and screening
tests). Individuals with persistent health anxiety are
more likely to believe that unexplained bodily changes
indicate serious underlying pathology (Salkovskis &
Warwick, 2001).
According to the cognitive behavioural interpreta-
tion of health anxiety, general health beliefs influence
the interpretations of bodily stimuli (Salkovskis &
Warwick, 2001), especially when people hold beliefs
about their own predisposition for a specific illness.
Such beliefs may be triggered by critical events, for
example information about a friend’s illness, unusual
and/or unexplained bodily sensations, new illness
information (Salkovskis & Warwick 2001).
The autonomic arousal that accompanies anxiety
generates symptoms that may be perceived as further
indication of physical abnormality, with increased
vigilance resulting in the detection of additional
bodily sensations and/or variations (Salkovskis &
Warwick, 2001). People with consistently higher
health anxiety continue to seek information about
their health status to substantiate the concern, having
a heightened awareness of the implications of a mis-
diagnosis, for example incorrectly perceiving a healthy
state when disease is actually present (Salkovskis &
Warwick, 2001). These individuals focus on informa-
tion that may indicate illness but ignore seemingly
contradictory information, even from their medical
practitioner (Salkovskis & Warwick, 2001; Warwick &
Salkovskis, 1990).
The cognitive behavioural model of health anxiety
seeks to identify behavioural manifestations such as
avoidance of strenuous physical activity and expo-
sure to disease, monitoring variations in bodily
events and appearance, repeated visits to the doctor,
reading health/illness books and seeking advice
and/or health information from significant others
(Salkovskis & Warwick, 2001; Warwick & Salkovskis,
1990). These behavioural responses are regarded as
‘safety-seeking’ behaviours because they represent

actions designed to assuage the perceived health
threat, for example to minimize or prevent the devel-
opment of feared illnesses and their perceived con-
sequences (Salkovskis & Warwick, 2001). However,
such behaviours may actually perpetuate elevated
health anxiety by increasing the attention on symp-
toms, with consequent increases in the perceived
intensity (and perhaps number) of symptoms and
level of somatic concern. In this sense such behav-
iours are maladaptive.
Other relevant behavioural issues
As an extension of the well-documented association
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between somatic symptoms, illness concern and
medical care-seeking (Creed & Barsky, 2004), Mewes
et al. (2008) reported that a higher number of visits
to medical practitioners by members of the general
population was related to more somatic symptoms
and a lower threshold for deciding when professional
advice was required. An issue related to use of health
services is reassurance seeking, with individuals who
experience conditions such as chronic pain, IBS and
CFS more likely to exhibit this behaviour. Moreover,
Rief et al. (2006) found that individuals with unex-
For personal use only.
plained symptoms responded less appropriately to
medical information. Despite information to the
contrary, these individuals were more inclined to
attribute symptoms to somatic explanations com-
pared with individuals who either had depression or
were healthy.
Avoidance behaviour has been identified as one of
the main characteristics of chronic pain. Specifically,
pain has been conceptualized within a ‘fear and
harm avoidance’ framework in which individuals
with chronic pain experience heightened anticipa-
tory anxiety when exposed to activities they believe
may exacerbate their pain (Lethem et al., 1983;
Turk & Okifuji, 2002; Vlaeyen & Linton, 2000).
Consequently, people strive to avoid situations per-
ceived as pain-eliciting and which increase the risk
of further injury (Crombez et al., 1998, 1999). Indi-
viduals also become particularly attuned to pain-
related cues (Crombez et al., 1998; Turk & Okifuji,
2002) and may avoid situations which trigger the
perception of pain. Greater disability is evident
among those who express pain- and activity-related
fear (Crombez et al., 1998; Vlaeyen et al., 2002;
Waddell et al., 1993), with this relationship at least
partly attributed to the physical consequences (e.g.
reduced muscle strength, lower endurance) of the
reduced activity that characterizes fear avoidance
behaviour (Hildebrandt et al., 1997; Lethem et al.,
1983; Turk & Okifuji, 2002).
Notably, a prospective investigation by Ströhle
et al. (2007) showed that unexplained somatic
conditions were less likely to be diagnosed among
Illness behaviour 9
adolescents and young adults with a more physically
active lifestyle. For individuals with low back pain,
Chou and Shekelle (2010) found that the most con-
sistent predictors of poorer health outcomes were
inappropriate behavioural responses to pain (e.g.
excessive fear avoidance), along with greater func-
tional disability, concomitant psychological distress
and poorer general health.
Given that inactivity confers few therapeutic ben-
efits, instead promoting disability and maintenance
of pain (Gatchel et al., 2007), behavioural therapies
are designed to increase engagement in day-to-day
activities by providing positive reinforcement for suc-
cessive approximations to higher functioning (Turk
& Monarch, 2002). Such behavioural approaches
also target the fear and harm avoidance characteris-
tic of chronic pain by placing people in feared situ-
ations gradually (Stiles & Wright, 2008).
The responses of significant others may perpetuate
maladaptive pain behaviour and should be directed
instead at reinforcing attempts to undertake activities
of daily living and decrease the attention on pain
behaviour, for example groaning or limping (Stiles &
Wright, 2008; Turk & Monarch, 2002; Turk et al.,
2008). Similarly, employers may design a return-
to-work programme encouraging the gradual resump-
tion of activities.
Martin and Rief (2011) identified the need for
research to examine the degree to which the fear
avoidance framework extends beyond the chronic
pain context to the situation of people with other
types of somatic symptom disorders. Notably, Rief
et al. (2010) found that the strongest predictor of
medical care-seeking and disability among indi-
viduals with somatic symptoms was the avoidance
of activity associated with increased heart rate or
perspiration.
Measures of illness behaviour
While the preceding commentary focused on the
main perspectives that characterize behavioural
responses to perceived illness, it is important to also
consider how illness behaviour has been operational-
ized. One of the most comprehensive attempts is the
Symptom Response Questionnaire (SRQ) (Egan &
Beaton, 1987), designed to compare responses to
commonly experienced somatic symptoms between
healthy individuals (who rarely sought medical care),
and those who frequently sought care (e.g. for chronic
headache, hypertension, pain and gastrointestinal
complaints). Twelve behaviours (e.g. ‘ignore it and
go on with activities’, ‘treat it with over-the-counter
medications’, ‘contact a physician’) are presented to
respondents who indicate those that they would use
to deal with 13 common somatic symptoms (e.g.
‘a cough lasting three days’, ‘a cold going into its
 10 K. N. Prior & M. J. Bond
second week’). Three subscales have been derived:
‘self help’ (e.g. reduce social activities, seek bed rest,
reduce work activities, use over-the-counter medica-
tion), ‘professional help’ (e.g. visit a doctor, do not
ignore symptoms, use prescribed medication), and
‘think and talk’ or ‘obsess’ (e.g. consider the possible
cause, talk to others).
Self-regulatory model of illness behaviour and coping
The self-regulatory model of illness behaviour (SRM)
(Brownlee et al., 2000; Diefenbach & Leventhal,
1996; Leventhal et al., 1997, 2001) has typically
operationalized responses to illness in terms of cop-
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ing strategies (Hagger & Orbell, 2003) such as those
measured by the Coping Orientation to Problems
Experienced inventory (COPE) (Buick & Petrie,
2002; Carver et al., 1989; Moss-Morris et al., 1996;
Steed et al., 1999). A key premise of the SRM is that
an individual selects and subsequently implements a
strategy designed to manage a threatening health
situation (i.e. procedural coping, Leventhal et al.,
1997). That is, active problem solving is used to
make sense of the perceived symptoms and to return
to his/her previous state of health (Diefenbach &
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Leventhal, 1996; Horne, 1997; Leventhal et al.,
2001; Ogden, 2000).
Use of the adjective ‘active’ may not accurately
portray procedural coping (Lau, 1997; Leventhal
et al., 1980). Indeed, reference to such strategies as
‘procedures’ is considered more all-encompassing
and, unlike a term such as ‘coping’, does not imply
the expected efficacy of a particular strategy (Leven-
thal et al., 1997). While many strategies represent an
appropriate form of action given the nature of pre-
senting symptoms (e.g. ‘discuss symptoms with sig-
nificant others’, ‘seek further information from
medical books’, ‘go to the doctor’. Cameron et al.,
1993; Carver et al., 1989), others do not necessarily
reflect an ‘active’ or adaptive approach. Any assess-
ment of the perceived appropriateness of a particular
strategy should take into account the stage at which
it is introduced during the illness episode (Leventhal
& Benyamini, 2001). For example, some people may
ruminate about a particular symptom, become dis-
tressed and then seek medical treatment. Others may
adopt passive management by withdrawing from per-
sonal and/or social obligations, resting and seeking
frequent medical consultations.
Behavioural aspects of health anxiety
The development of the Health Anxiety Inventory
(HAI) (Salkovskis et al., 2002) was informed by the
cognitive behavioural conceptualization of health
anxiety. The HAI comprises behaviourally orientated
items (e.g. ‘examination of body’, ‘ignore/focus on
unexplained bodily sensations’) and two scales that
tap the seemingly central illness behaviour domains
of ‘reassurance seeking’ (from sources such as
‘friends’, ‘family’, and by ‘reading books’) and ‘avoid-
ance behaviour’ (e.g. ‘consulting your family doctor’,
‘talking about illness’ and ‘reading about illness’)
(Salkovskis et al., 2002; Warwick & Salkovskis, 1989).
As expected, the mean HAI score was significantly
higher for individuals with hypochondriasis than
among those with a diagnosed anxiety disorder,
women seeking the advice of their GP, and a control
group (Salkovskis et al., 2002). However, a brief
14-item version (SHAI) (Salkovskis et al., 2002) of
the original 47-item instrument has had greater
appeal to researchers. Unfortunately, the SHAI
appears to lack the overt behavioural items included
in the longer version and the reassurance-seeking
and avoidance behaviour scales devised originally by
Salkovskis et al. (2002) are typically disregarded.
Illness Behaviour Questionnaire
The most notable measure of AIB is the Illness
Behaviour Questionnaire (IBQ) (Pilowsky & Spence,
1983, 1994), an expanded version of the original
Whiteley Index of hypochondriasis (WI) (Pilowsky,
1967), that measured ‘bodily preoccupation’, ‘dis-
ease phobia’, and ‘conviction of the presence of dis-
ease’. The 62-item IBQ comprises seven primary
scales: ‘general hypochondriasis’, ‘disease convic-
tion’, ‘psychological versus somatic focusing’, and
‘denial’ (purported to be direct measures of cogni-
tion), and ‘affective inhibition’, ‘affective distur-
bance’, and ‘irritability’ (measures of affect; Pilowsky
& Spence, 1983, 1994). Two second order factors are
also commonly derived, with ‘disease affirmation’ a
composite measure comprising ‘disease conviction’
and ‘psychological versus somatic focusing’, and
‘affective state’ consisting of ‘general hypochondria-
sis’, ‘affective disturbance’ and ‘irritability’ (Pilowsky
& Spence, 1983, 1994). Notably, the IBQ (Pilowsky
& Spence, 1983, 1994) is not designed specifically
for diagnostic purposes (i.e. to determine the pres-
ence or absence of an ‘abnormal illness behaviour’
case; Pilowsky, 1996; Pilowsky & Spence, 1988).
A later development was Form B (Pilowsky &
Spence, 1994) which does not assume the presence
of a current specific illness and, unlike the original
version (Form A), is therefore able to be administered
to members of the general community. Form B con-
tains parallel items to Form A, with a number having
been reworded to improve their relevance to the gen-
eral community. While Pilowsky and colleagues do
not appear to have conducted any empirical research
using Form B, it was used by Boyle and Le Déan
(2000) to assess AIB among healthy university stu-
dents and adult members of the general community.

The first three primary IBQ factors are used most
commonly to characterize inappropriate responses
to illness. Those with high scores for ‘disease convic-
tion’ believe that something is seriously wrong with
their bodies and that illness interferes substantially
with day-to-day activities (Pilowsky & Spence, 1983,
1994). A low score for ‘psychological versus somatic
focusing’ reflects a preoccupation with physical
symptoms and a greater propensity for somatiza-
tion. Conversely, people with a high score attribute
symptoms to underlying psychological concerns
(Pilowsky & Spence, 1983, 1994). ‘General hypo-
chondriasis’ measures the extent to which a person
is fearful of illness (Pilowsky, 1997). Those with
Int Rev Psychiatry Downloaded from informahealthcare.com by University of Queensland on 10/15/14
high scores believe that they might unexpectedly
become ill and worry about the possibility of devel-
oping a condition that has been brought to their
attention in the media.
The screening version of the IBQ (SIBQ)
(Chaturvedi et al., 1996) comprises 11 items argued
to be the most clinically representative of AIB, and has
the advantage of a shorter administration time. Items
derive from the ‘disease conviction’ and ‘psychological
versus somatic focusing’ scales, with a score of seven
or higher indicative of AIB. Waddell et al. (1989) have
For personal use only.
also recommended ‘disease conviction’ as a more par-
simonious classification of AIB, proposing that a score
of three or more is diagnostic.
A standardized interview known as the Illness
Behavior Assessment Schedule (IBAS) (Pilowsky
et al., 1983) has also been devised to assess specific
clinical aspects of AIB. The IBAS was validated with
individuals from a psychiatric inpatient clinic and
those attending pain and rheumatology outpatient
clinics, with the patterns of response among these
three groups in accord with both theoretical and
clinical expectations (Pilowsky et al., 1983). That is,
the psychiatric patients acknowledged more affective
difficulties with recognition of the contribution of
psychological factors to their illness. Conversely, pain
patients showed greater symptom awareness and dis-
ease preoccupation. Rheumatology patients provided
responses consistent with a greater somatic than psy-
chological focus, with less extreme illness attitudes
than those of the pain and psychiatric patients. How-
ever, the IBAS is rarely used. The labour intensive
nature of data collection (i.e. one-on-one clinical
interviews) presumably militates against its use.
Criticisms of the IBQ
While the IBQ has a long history of application, it
attracts several key criticisms (Prior & Bond, 2008).
First, its factor structure has been criticized (Byrne
& Whyte, 1978; Zonderman et al., 1985), with the
suggestion that too many factors have been reported
previously (Main & Waddell, 1987). Alternative
Illness behaviour 11
factor structures have perpetuated the debate about
the dimensions which best characterize AIB. Sec-
ond, given that the IBQ has been validated most
commonly with patients with chronic pain or a psy-
chiatric condition, there is a need to examine more
systematically the extent to which IBQ responses
vary across and within types of illness (Byrne &
Whyte, 1978, 1979; Mayou, 1986, 1989; Zonderman
et al., 1985).
Third, despite the existence of Form B of the
IBQ, there has been minimal exploration of what
AIB might represent for members of the general
community (Boyle & Le Déan, 2000; Currie et al.,
1999; Zonderman et al., 1985). Fourth, the IBQ
(Pilowsky & Spence, 1983, 1994) has been criti-
cized for its adequacy as a generic measure of inap-
propriate illness behaviour (Duddu et al., 2006;
Mayou, 1989; McDowell & Newell, 1996) because
there are no items that target directly the overt
behaviours (e.g. bodily checking, reassurance seek-
ing, avoidance) indicative of conditions such as
hypochondriasis (Stewart & Watt, 2001). At best,
indices such as formal help-seeking and pain behav-
iours have been used to examine behavioural con-
comitants in conjunction with IBQ dimensions (e.g.
Keefe et al., 1986; Pilowsky et al., 1987; Scicchitano
et al., 1996).
New Abridged Version of the IBQ
In a preliminary attempt to address the aforemen-
tioned shortcomings, Prior and Bond (2010) under-
took a re-evaluation of the IBQ using a statistically
rigorous factor analysis approach. Three new IBQ
dimensions demonstrated sound internal reliability
for both general community members and partici-
pants with either asthma, diabetes, chronic pain or
CFS. These scales were termed ‘affirmation of ill-
ness’ (AI), ‘concern for health’ (CH), and ‘general
affective state’ (GAS), with evidence that scores
varied both with health status and illness character-
istics. Further, the item composition of the CH
scale highlighted potential conceptual overlap with
health anxiety.
For each illness sample, individuals with a more
severe condition reported higher scores, particularly
AI. In general, lower scores were reported by com-
munity members, followed by those with either
asthma or diabetes, and finally those with either
chronic pain or CFS. The more complex symptom
profile and broader functional limitations associated
with pain (Adams et al., 2006; Blyth et al., 2001;
Douglas et al., 2004; Gatchel et al., 2007; Turk &
Monarch, 2002) and CFS (Afari & Buchwald, 2003;
Cho et al., 2006; Fukuda et al., 1994) may elicit
responses traditionally characteristic of AIB. Con-
versely, a typically episodic condition such as asthma
 12 K. N. Prior & M. J. Bond
(Chung, 2002; NACA, 2002, 2006) may less readily
influence a person’s interpretation of, and response
to, illness. These observations question the extent to
which a pattern of affirmative IBQ responses is
indicative of a genuine somatic symptom disorder
(i.e. AIB), as opposed to merely characterizing a
reasoned interpretation of the nature and severity
of the illness experience (Byrne & Whyte, 1978,
1979; Mayou, 1986, 1989; Waddell et al., 1989;
Zonderman et al., 1985).
Prior and Bond (2010) suggested that scores for
the three new IBQ dimensions be presented as con-
tinua rather than dichotomous variables for which
particular cut-offs may be used to indicate possible
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‘AIB’ cases. Indeed, Pilowsky (1994) also recom-
mended that AIB be construed as a dimensional
construct, with abnormal forms of illness behaviour
represented as extremes (Pilowsky & Spence, 1994).
Moreover, in the absence of further clinical informa-
tion it would be unwise to specify values which may
distinguish individuals who behave inappropriately
in response to illness. The potential role of such
clinical thresholds would require more focused
attention in future investigations. Renewed efforts to
operationalize AIB, such as by Prior and Bond
For personal use only.
(2010), may help to address the need for diagnostic
information in the DSM to be supplemented with
detailed information about concomitant psycholo-
gical factors (e.g. health beliefs, illness behaviour)
that may contribute to the perception of physical
symptoms (Mayou et al., 2005; Rief & Hiller, 1998;
Rief & Isaac, 2007; Sharpe & Mayou, 2004; Sharpe
et al., 2006).
Alternative measures of illness behaviour
Scale for the Assessment of Illness Behaviour
Given that other instruments focus predominantly
on cognitive and affective behaviours, Rief et al.
(2003) developed the Scale for the Assessment of
Illness Behaviour (SAIB) to characterize overt illness
behaviour. The 26-item SAIB comprises five scales:
‘verification of diagnosis’, ‘expression of symptoms’,
‘medication/treatment’, ‘consequences of illness’,
and ‘body scanning.’ Higher scores represent the
endorsement of more maladaptive illness behaviours
(Rief et al., 2003).
The SAIB was validated with inpatients with psy-
chiatric and psychosomatic conditions, and healthy
hospital staff (Rief et al., 2003). The inpatient sample
comprised people with either major depression, som-
atization syndrome, or both. Although a 4-factor
model was the most meaningful solution, ‘scanning’
was also included in the final version because it fea-
tured consistently in other investigations. Clinically,
scanning was considered to be a key illness behaviour.
While Rief et al. (2003) reported a final 26-item
SAIB, some excised items appear in an expanded
51-item version.
Psychometric information was reported for the
26-item version only (Rief et al., 2003), with evi-
dence of satisfactory internal consistency. The rela-
tively modest inter-associations among the SAIB
dimensions supported the notion that illness behav-
iour comprises multiple dimensions. Concurrent
validity was sought by examining the associations
between SAIB scores and doctors’ ratings of illness
behaviour. Each component of the rating shared a
significant association with ‘consequences of illness’,
while more ‘scanning’ related to greater symptom
focusing (Rief et al., 2003). For patients, higher neu-
roticism was associated with more perceived illness
consequences, greater scanning and more maladap-
tive illness behaviour in general. Patients with higher
phobic anxiety experienced generally poorer illness
behaviour and scored more poorly for ‘medication’
and ‘scanning’. People with higher somatization
index scores were more likely to endorse the ‘verifi-
cation of diagnosis’ scale (Rief et al., 2003). The
patient sample as a whole differed significantly from
the control group for total, ‘verification of diagno-
sis’, ‘consequences of illness’ and ‘scanning’ scores.
In a subsequent study involving general community
members, greater somatization was associated with
higher levels of ‘medication/treatment’ and ‘body
scanning’ (Rief et al., 2005). Given that the SAIB
was tailored to the psychiatric context, Petrie and
Broadbent (2003) suggest that it may contribute to
a better understanding of behavioural responses
characteristic of conditions without a clearly identi-
fied pathophysiological mechanism (e.g. chronic
pain or CFS).
Behavioural Responses to Illness Questionnaire
Uniquely, the Behavioural Responses to Illness
Questionnaire (BRIQ) (Spence et al., 2005) aims to
assess behaviour during acute illness. Moreover,
Spence et al. (2005) proposed that such behaviours
may contribute to the development of enduring
somatic presentations disproportionate to objective
abnormality (i.e. ‘medically unexplained’ or ‘func-
tional’ somatic syndromes). The four subscales
derived for both university students (who responded
to a hypothetical acute illness) and individuals diag-
nosed with gastroenteritis were: ‘all-or-nothing behav-
iour’, ‘limiting behaviour’, ‘emotional support
seeking’, and ‘practical support seeking’ (Spence
et al., 2005). Respondents indicated the frequency
with which they engaged in each of 21 behaviours.
While higher levels of ‘limiting behaviour’ (e.g. restrict-
ing usual life activities) and ‘practical support seeking’
(e.g. assistance from significant others) at the time of

infection were evident among people who did not
develop IBS, those who met criteria for IBS at
3-month follow-up were more likely to have engaged
in ‘all-or-nothing behaviour’ (i.e. elevated level of activ-
ity until the person’s physical resources are exhausted)
at the time of the acute illness (Spence et al., 2005).
The BRIQ sought to characterize more generic ill-
ness behaviours by referring to the potential roles of
significant others and the need for activity reduction.
Notably, a medical help-seeking scale was excluded
from the BRIQ due to low internal consistency.
Given that responses to the BRIQ were made with
respect to illnesses such as gastroenteritis that are
typically self-limiting, self-management behaviours
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(e.g. temporary reduction in activity, practical assis-
tance from others) may be more pertinent than for-
mal medical intervention.
Future research directions
State-based versus trait-based features of behaviour
The literature on behavioural concomitants of
somatic symptom disorders is likely to be advanced
by closer examination of the state-based versus trait-
For personal use only.
based characteristics of illness behaviour. Such
research has not been conducted previously. The
dimensions derived from the IBQ by Prior and Bond
(2010), along with the availability of the SAIB (Rief
et al., 2003) and the BRIQ (Spence et al., 2005),
provide an opportunity to compare the extent to
which the domains of these instruments measure
situation-specific or more enduring aspects of illness
behaviour. An important corollary of such an inves-
tigation would be to distinguish between behaviours
associated with greater risk of developing a somatic
symptom disorder (e.g. behaviours measured by the
BRIQ (Spence et al., 2005)) as opposed to behav-
iours which suggest psychological adaptation to such
a diagnosis (e.g. SAIB (Rief et al., 2003)).
Affective concomitants of illness behaviour
Cameron and Jago (2008) have examined the strate-
gies employed to manage emotional responses to ill-
ness (e.g. anxiety or fear) with respect to the broader
domains of attention (i.e. vigilance or avoidance),
proactive behaviour (e.g. help-seeking), cognitive
reappraisal (e.g. recognizing potential benefits of the
situation), and response regulation (e.g. relaxation,
substance use). Notably, this conceptualization
acknowledges the inter-dependence of behaviours
designed to modify aspects of the illness and those
targeting emotional concomitants, with the possibil-
ity of incompatibility on occasions (Cameron & Jago,
2008). For example, the discovery of a lump may
evoke fear of cancer (i.e. an emotional response) and
Illness behaviour 13
be associated with the behavioural response of
delay in seeking care. However, this avoidance behav-
iour may conflict with the individual’s knowledge
(i.e. cognition) that delay behaviour increases the
seriousness of the health threat (Lau, 1997). Cogni-
tive representations of illness (e.g. perceptions of
acute versus chronic illness) may influence the type
of strategies used to manage emotion (Cameron &
Jago, 2008).
In terms of improving the understanding of behav-
iours associated with somatic symptom disorders, a
valuable starting point may be to explore the degree
to which individuals with these conditions have par-
ticular cognitive and emotional representations of
illness. A logical extension of such research would be
to examine the behavioural implications (e.g. fre-
quent care-seeking and delay behaviour) of beliefs
and emotions identified as potentially maladaptive,
with Petrie et al. (2007) acknowledging associations
between illness perceptions and use of healthcare.
Particular attention may be given to occasions when
there is incompatibility between behavioural responses
to the illness and concomitant emotions (Cameron
& Jago, 2008), with attempts to identify cognitive and
affective precursors to such behaviour.
Positive illness behaviours
Rather than focusing exclusively on behaviours with
a maladaptive emphasis (e.g. avoidance behaviour,
excessive healthcare-seeking), there is a need to
examine more specifically behaviours of a construc-
tive nature which may minimize the risk of develop-
ing a somatic symptom disorder. Specifically, the
potential relevance of constructs such as resilience,
appropriate healthcare-seeking and adaptive coping
to the somatic symptom context is worthy of explo-
ration to determine the extent to which they
are associated with better health outcomes for indi-
viduals who are preoccupied excessively with their
physical health. The opportunity to learn adaptive
responses to somatic information may equip these
individuals with the skills to respond more appropri-
ately to typical fluctuations in somatic cues and be
more discerning about situations which require for-
mal medical care.
The ability of individuals to manage physical
symptoms more effectively outside the formal medi-
cal setting may be enhanced by the acquisition of
self-management strategies (Lorig, 1996; Lorig &
Holman, 2003; Newman et al., 2004). For those who
meet the criteria for a somatic symptom disorder it
may be useful to examine the extent to which they
engage in appropriate self-management. The avail-
ability of concrete, specific behaviours which can be
performed without the direct assistance of a medical
practitioner may allow individuals to respond to
 14 K. N. Prior & M. J. Bond
perceived symptoms in a more systematic, controlled
manner. Moreover, individuals who pursue informal
self-management options initially may be able to
increase their threshold for deciding when medical
care is warranted (Mewes et al., 2008). Importantly,
self-management may help to reduce the intensity
and frequency of symptoms, and in some cases even
alter the perceived need for formal care-seeking.
Similarly, it would be valuable to explore the type
of coping strategies used by people with somatic
symptom disorders. For example, Rasmussen et al.
(2010) reported greater use of emotion-focused cop-
ing by individuals recruited from a primary care clinic
who met criteria for abridged somatization. However,
Int Rev Psychiatry Downloaded from informahealthcare.com by University of Queensland on 10/15/14
the potential disadvantage of relying on coping mea-
sures exclusively is that types of coping (e.g. problem
focused or emotion focused) may not be inherently
(mal)adaptive, with their potential value dependent
upon the circumstances of a person at a particular
point in time (Folkman & Moskowitz, 2004).
Concluding comments
Rather than conducting further isolated investiga-
For personal use only.
tions of illness behaviour, there is a need for a more
coordinated approach to the collection of behavioural
information. Given the diverse theoretical perspec-
tives which have already informed the conceptualiza-
tion of illness behaviour, attention now needs to focus
more specifically on the precise and reliable opera-
tionalization of the overt behavioural characteristics
of somatic symptom disorders. Researchers need to
compare more directly the relative strengths and
limitations of existing measures (e.g. IBQ, SAIB,
BRIQ) to determine the contribution each instru-
ment makes to the understanding of somatic presen-
tations. Such information could be used clinically to
assist with the identification of individuals either at
risk of developing a somatic symptom disorder or
who already meet diagnostic criteria for such a pre-
sentation. A better understanding of the behavioural
concomitants of different somatic symptom presenta-
tions would enable clinicians to develop interventions
which target the overt behaviours exhibited more
specifically rather than just the cognitive and affective
components of these conditions. Individuals who are
encouraged to learn more adaptive behavioural
responses to bodily information (i.e. informal self-
management) may experience less intense and dis-
ruptive somatic conditions, and ultimately, improved
physical and psychosocial functioning.
Two take-home points arising from the review
Behavioural aspects of somatic symptom disorders
may be informed by the general sociological notion
of illness behaviour, along with the associated litera-
tures on abnormal illness behaviour and health anx-
iety, and measurement of illness behaviour has been
limited by the paucity of instruments which target
overt behaviours specifically.
Two key future directions
Future research needs to distinguish between the
state-based and trait-based characteristics of illness
behaviour more specifically, and the potential value
of adaptive illness behaviours in either reducing
the risk of developing a somatic symptom disorder
or minimizing the adverse psychosocial conseq-
uences of such a presentation is worthy of empirical
exploration.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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