Effects of gender and marital status on somatic symptoms of patients attending a Mind/Body Medicine Clinic

Effects of gender and marital status on somatic symptoms of patients attending a Mind/Body Medicine Clinic – Statistical Data Included

Mutsuhiro Nakao

Editors’ Note. In this issue, a team of six authors present three studies that assess the characteristics of more than 1,000 patients who participated in the Medical Symptom Reduction Program of the Mind/Body Medical Institute at the Beth Israel Deaconess Medical Center in Boston. The program was established 20 years ago and has reported success in reducing medical symptoms across a broad range of conditions.

Although the three articles do not include a control group or report long-term follow-up studies on the treatments, the large sample of patients provided a unique opportunity to explore predictors of outcomes and analyze factors that contribute to dropout rates among patients who enroll in such programs. The studies assessed the influence of education on drop-out rates, analyzed changes in somatization from the beginning to the end of the program, and found specific gender differences in reporting somatic discomfort. The authors’ findings may be helpful to physicians and other professional clinicians in making decisions about referring patients for mind/body behavioral medicine treatments.

Physical symptoms are the major reason for outpatient visits to primary care physicians, (1,2) with reports of fatigue, back pain, headache, dizziness, chest pain, shortness of breath, abdominal pain, and anxiety accounting for more than 80 million physician visits annually. These complaints constitute approximately one fourth of the visits to internists’ offices, (1) yet the causes and treatments for such conditions are less obvious than for well-defined diseases (3-5) because mind/body factors affect the degree of patients’ symptoms.

Several studies conducted in different settings have reported that women report more somatic symptoms than men do. (6-9) At least five possible gender-related factors contribute to this phenomenon. (6,7)

1. Some of the differences in somatization between women and men may be related to the style of reporting. The belief that men are more reluctant than women to admit somatic distress and feelings of illness may reflect cultural traits, echoed in phrases such as “boys don’t cry.” (10) Boys are taught to be stoic and to ignore symptoms; therefore, they may develop a higher threshold for reporting somatic complaints.

2. Several studies have demonstrated that women have a lower threshold for visiting the doctor. (10-12) The apparent gender differences in somatic symptoms may result from gender differences in “sick role” behavior rather than from differences in bodily sensation.

3. Research evidence suggests that both depression and anxiety disorders are common in women (13-16) and that these illnesses are often concomitant with somatic symptoms. (17,18)

4. It has been reported that individuals who live alone or in social isolation are prone to develop physical symptoms. (19) Women may be more likely than men to be socially isolated because their average life expectancy is longer than men’s.

5. It is possible that women are simply more sensitive to bodily stimuli and experience more somatic distress than men. (20,21)

Previous studies of reported symptoms have used samples drawn from the general population or from primary care settings. (8,9,22-24) It is unclear what proportion of reported symptoms are clinically significant and to what extent they may be accompanied by psychiatric or psychosomatic characteristics. In addition, few studies of somatic symptoms have focused on the influence of marital status. (25) Because analyses of prospective data indicate that being married has beneficial effects on health, (26-28) marital status may influence gender differences in reporting somatic symptoms.

In our present study, we attempted to accomplish two research tasks: (a) to estimate the gender-specific frequency of somatic symptoms in a mind/body clinic population, and (b) to assess the effect of marital status on gender differences in somatic symptoms. We focused on the relationships among gender, marital status, somatic symptoms, psychological distress, and stress perception.


The Mind/Body Program

The Mind/Body Medical Clinic is located at the Beth Israel Deaconess Medical Center, a tertiary care hospital affiliated with Harvard Medical School in Boston, Massachusetts. The 10-week Medical Symptom Reduction Program, which provided the data we used in this study, is an integrated program in the Division of Behavioral Medicine. It consists of weekly 2-hour sessions that include training in eliciting the relaxation response, stress management, exercise, and nutrition. (29)

Staff members in the department routinely send information describing clinic treatment plans, program goals, conditions or disorders treated, and insurance coverage to primary care physicians in the hospital and in Boston. No specific disease criteria are required for entry into the Medical Symptom Reduction program. Referred patients include individuals complaining of general stress-related physical symptoms, including headache, gastrointestinal pain, and palpitations. Patients with cancer, cardiac disease, infertility, or HIV-positive status attend disease-specific mind/body programs. Information about the specialties of referring physicians, available from the Board of Registration in Medicine for Massachusetts, is shown in Table 1.


From 1993 to 1997, 1,168 patients enrolled in the Medical Symptom Reduction Program. Their medical records were filed in the Beth Israel Deaconess Medical Center. We did not include details from 6 patients in the clinic database because of inadequate information. In addition, we did not analyze data from widowed patients (26 women and 4 men) because the sample was relatively small, especially for men, compared with married, single, and divorced or separated individuals. Thus, we included 1,132 new outpatients (848 women and 284 men) with stress-related conditions in the study. Before their participation, we explained the nature of the study; all of the patients gave their written, informed consent to participation.

For demographic characteristics of the patients in the sample, see Table 1. The ratio of married to nonmarried patients was significantly lower in women than in men. We did not analyze the data in terms of race because more than 90% of the patients were White. Their diagnoses were based on the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10). (30)

Migraine was more common in the women participants, whereas essential hypertension was more common in the men. Although not shown in the table, 17 women (2%) had genitourinary diseases, including menstrual disorders.

Assessment of Somatic Symptoms

We used the Medical Symptom Checklist to assess 12 major somatic symptoms at the patients’ first interview. Patients indicated the frequency, degree of discomfort, and degree of interference with daily activities of 23 to 25 medical symptoms. Using previous studies among primary care patients as a guide, (8) we selected the following common major symptoms for analyses in the study: fatigue, insomnia, headache, back pain, joint or limb pain, abdominal pain, shortness of breath, palpitations, constipation, chest pain, nausea, and dizziness.

We scored the frequency of each symptom as ordinal categorical data as follows: never or almost never (0); less than once a month (1); once to twice a month (2); once a week (3); 2 to 3 times a week (4); 4 to 6 times a week (5); once a day (6); more than once a day (7). Symptoms scored as occurring once a week or more often (scores of 3 or more) were defined as symptom-positive.

Assessment of Psychological Distress

In addition to appraising somatic symptoms, we assessed somatization, depression, and anxiety levels, using the Symptom Checklist-90 Revised (SCL-90R), (31) a standardized questionnaire. The SCL-90R is a 90-item self-report symptom inventory; each item is rated on a 5-point scale of distress, ranging from not-at-all (0) to extremely (4).

The 90 items are scored and interpreted in terms of 9 primary symptom dimensions and one global severity index of distress. The dimensions are labeled somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. According to previous studies, (32,33) the 9 dimensions have a test-retest reliability ranging from .78 to .90 and validity of .40 to .75 with the Minnesota Multiphasic Personality Inventory.

Assessment of Stress Perception

We used an 11-point scale to assess stress perception in 7 areas (work-, family-, neighborhood-, living-, social-, financial-, and health-related situations). Responses ranged from no stress (0) to worst stress possible (10).

Data Analysis

We calculated the percentage of patients who experienced each somatic symptom separately for women and for men, using chi-square tests to determine significant differences in each symptom between women and men and among married, single, and divorced or separated patients. To investigate the odds ratio of each symptom for women, we used multiple logistic regression analysis, adjusting for the effects of age, marital status, education, employment, and SCL-90R depression and anxiety scales. We also used multiple logistic regression for the odds ratios of each symptom for single (vs married) and for divorced or separated (vs married patients), adjusting for the effects of age, sex, education, employment, and SCL-90R depression and anxiety scales.

We calculated the means and standard deviations of the scores of the SCL-90R and stress perception scales. In addition to the SCL-90R raw scores, we analyzed t scores from the general population, normalized by gender. (33) To examine gender differences in our specific study sample, we analyzed the SCL-90R raw scores and the SCL-90R t scores to determine how deviant our female or male participants were from the normative scores of women or men in the healthy population (M = 50).

Finally, we used analysis of covariance to compare the SCL-90R raw scores and t scores between women and men, controlling for the effects of age. We also used analysis of covariance for the SCL-90R and Stress Perception scores to examine the main effects of gender, age, and marital status and their interactions.

Next, we calculated a total symptom score (0-12) by summing the number of symptoms counted as positive and used analysis of covariance to compare the total symptom scores between women and men, controlling for the effects of age. Multiple linear regression analysis was also performed to determine the independent effects of gender, age, marital status, education, employment, and SCL-90R depression and anxiety scales on the total symptom score. We used the SAS statistical package (34) to perform all of these analyses.


Somatic Symptoms

The prevalence of 4 symptoms–fatigue, headache, constipation, and nausea–was significantly higher in women than in men, controlling for the effects of age, marital status, education, employment, depression, and anxiety (see Table 2). We observed that being a woman was a significant predictor for the 5 most common symptoms (ie, fatigue, insomnia, headache, back pain, and joint or limb pain) and for 4 other symptoms–palpitations, constipation, nausea, and dizziness. We found no significant gender differences in the 3 remaining symptoms–abdominal pain, shortness of breath, and chest pain.

Being single was a significant predictor for insomnia, and being divorced or separated was a significant predictor for shortness of breath, controlling for the effects of age, sex, education, employment, depression, and anxiety. In women, the prevalence of fatigue and nausea was significantly different among married, single, and divorced or separated patients, and was highest in the single patients. In men, the prevalence of all of the symptoms was comparable among the three marital status groups.

Total Symptom Score

We found that total symptom scores were significantly higher in women than in men. Scores were significantly higher in female patients with chest pain than in male patients with this diagnosis (see Table 3).

In the entire sample, the results of multiple linear regression analysis indicated that 4 out of 7 variables (ie, anxiety, female sex, depression, and young age) were significant predictors of the total symptom score, F = 12.7, p < .01. By contrast, marital status, education, and employment were not significant predictors (see Table 4).


The raw scores on somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, and global severity index scales were significantly higher in women than in men (see Table 5). By contrast, the t scores on all of the SCL-90R scales were significantly higher in men. The t score results of the analysis of covariance indicated that gender had a significant main effect, using raw scores on the following 8 scales: somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, paranoid ideation, psychoticism, and global severity index (see Table 6).

We found main effects of marital status were significant on obsessive-compulsiveness, depression, paranoid ideation, psychoticism, and the global severity index. Scores on those scales were lower in the married patients than in the nonmarried patients, but we noted only small differences between the single and divorced or separated patients. However, we found no significant interaction effect of gender and marital status on any of the 10 scales.

Stress Perception

The results of the analysis of covariance indicated that gender had a significant main effect on the perception of stress in the areas of work, family, and health. Men felt significantly more work stress than women did, but women experienced significantly more stress in regard to family and health. We also found a significant main effect of marital status On social, financial, and living situations. The married patients reported less stress in these areas than the nonmarried patients; we also found a significant interaction effect of gender and marital status on financial-related stress.


In the present study, we examined gender differences in somatic symptoms at a mind/body outpatient clinic. Female gender was a significant predictor of the frequency of 9 out of 12 symptoms and was also associated with the total number of somatic symptoms. These findings parallel those of Kroenke and colleagues (8) in a sample of US primary care patients. Adjusted odds ratios of symptoms for women in that study (typically in the 1.5-2.5 range) showed statistically significant differences for 10 of 13 symptoms. Gender was the most important factor associated with symptom reporting in that study, even after adjusting for psychiatric comorbidity and other demographic variables.

All of the individuals in our study were referred to the clinic by their physicians, who judged that they were experiencing some form of mind/body distress. To measure the symptoms as objectively as possible, we assessed the frequency, rather than the severity, of each symptom. We adjusted analyses for other potential confounding factors, such as age, education, and mood states (anxiety and depression). The findings suggested that increased symptom reporting in women is a general phenomenon in mind/body clinic patients rather than a phenomenon restricted to certain types of symptoms.

Factors That May Account for Gender Differences

Women had significantly higher raw scores than men on the SCL-90R somatization scale. They also reported more symptoms on the Medical Symptom Checklist. These findings may be compatible with one possible factor in reporting somatic symptoms, namely, the willingness to admit discomfort. (6,7) Women’s tendency to disclose may be enhanced by the use of female interviewers in health surveys. Several researchers (35,36) have suggested that respondents are more likely to confide in interviewers of the same sex, whereas men may want to impress female interviewers with their vigor. To minimize the effects of interviewer characteristics, we had patients in this study report somatic symptoms on a self-rated questionnaire. However, differences between genders in reporting styles should be the subject of further study.

Approximately three times more female than male patients were referred to the Mind/Body Clinic. When the scores were standardized on the basis of data from the general population for each gender, women in this study deviated less from the normative women than the male patients did from the general male population group. One might assume that these findings support the second possible factor of gender differences in somatic symptoms (ie, the readiness to seek medical attention). (6,7) The male group of patients was smaller than the female group and reported higher somatization levels (compared with the general population) than female patients.

Researchers have noted that women report more symptoms more frequently than men do and also go to internists and psychiatrists more frequently. (37) As a result, female patients with mind/body distress may be referred to the clinic more often and for different reasons than men. Furthermore, a referral bias by physicians may also account for this difference. That is, the physicians may be more likely to refer men only with more severe somatizing complaints.

A third possible factor in gender differences, the prevalence of psychiatric disorders with prominent somatic features, (6,7) may be associated with depression and anxiety. We found that the raw scores for both the SCL-90R depression and anxiety scales were significantly higher in women than in men. These scales were independently associated with the total symptom score, controlling for the effects of gender and other demographic variables. Our findings were certainly consistent with the previous reports, (13-18) but female gender was still a significant predictor of somatic symptoms, even after accounting for the effects of depression and anxiety.

One suggestion was that gender differences in somatic symptoms could not be wholly explained by the effects of depression and anxiety. The female patients felt significantly more stress about family and health, whereas the male patients felt significantly more stress about work. These findings may be related to social interaction, the fourth possible factor in gender differences in symptoms. Some researchers have demonstrated that working men and women are better off than their unemployed counterparts and that individuals who live in social isolation are prone to develop physical symptoms. (19,38,39) Women reporting stress about family may have had total responsibility for a household, husband, and children, and had few adult contacts. Thus, they may fit into the category of the socially isolated. Interviews or questionnaires about social support could help us understand the relationship between family stress and women’s health.

Finally, a fifth possible factor in differences between men and women in somatosensory perception could be related to the gender differences in brain function reported by Kirn and Lombroso (40) and Fitch and Denenberg. (41) Women’s reproductive processes (the menstrual cycle, pregnancy, and menopause) produce a host of internal information that is absent in men. (42) Although we excluded conditions related to pregnancy and delivery from our study, we did not exclude women because of menopause or the menstrual cycle. Future study of gender differences and somatic symptoms need more specific information about the physiological differences between men and women.

According to 1998 Current Population Survey Reports about marital status and living arrangements (unpublished data), the percentage of married persons was comparable between women (63%) and men (61%) among White adults living in US metropolitan areas. Widowed persons were excluded from that calculation. In our study, however, the percentage of married patients was significantly greater in men than in women. Being single was a significant predictor of reports of insomnia, and being divorced or separated was a significant predictor of reports of shortness of breath.

The SCL-90R global severity index, as well as 4 other SCL-90R scales, was significantly lower in the married patients than in the single and divorced or separated patients. Married patients reported significantly less stress about social, financial, and living situations than single and divorced or separated participants.

Our findings in this study suggest that married patients are less likely to report physical and psychological distress. Questions that arise from these findings concern:

* The role of marriage as social support (43,44): Do single and divorced or separated patients lack access to the kinds of social support that are available to married patients?

* The effects of health conditions: Are healthy persons more likely to marry; are couples more likely to divorce if a spouse complains about various symptoms?

* The differences in reporting styles: Are married people less likely to refer to themselves as ill because they are reluctant to suffer the financial consequences of taking time off from work?

To answer these questions, marital satisfaction as well as social support could be measured in future studies.

Study Limitations

A major limitation in our study concerns the generalizability of the findings. We excluded widowed patients in the analysis because of the small (2.5%) sample. The findings may generalize only to White nonwidowed persons in New England with mind/body distress.

In addition, all of the participants had various medical conditions, but they were referred to the clinic because of stress-related symptoms. Symptoms may have been derived from specific types of chronic illnesses, and the effects of those conditions should be considered in future research.

In addition, we did not assess the patients’ medication regimens, although gender differences in reporting symptoms could be affected by differences in the regimen.

Finally, referring physicians used their own criteria for making referrals because no formal guidelines exist. The reasons physicians decide to refer or not to refer to a mind/body medicine clinic, as well as the gender, marital status, and age biases in their patient samples, should be examined.

In spite of these limitations, our findings have some important practical implications. Physicians and other professionals working in medical care settings should be aware of the close association between somatic and psychological symptoms in the clinical evaluation and management of their patients. Within the context of a thorough medical evaluation, gender and marital status may be important factors to consider when assessing these psychosomatic relationships.


Characteristics of Female and Male Patients With

Mind/Body Distress

Female Male

(n = 848) (n = 284)

n % n %

Marital status ([dagger])

Married 422 50 191 67 **

Single 321 38 73 26

Divorced/separated 105 12 20 7

Education (y)

Graduate school ([greater

than or equal to] 17) 370 44 145 51

College (13-16) 388 46 109 38

Grade/high school ([less than

or equal to] 12) 90 11 30 10

Occupation ([double dagger])

Employed 734 87 252 89

Student 26 3 9 3

Housewife/husband 23 3 5 2

Not employed 65 8 18 6

Referring physician

Internists ([section]) 570 67 185 65

General internists 283 33 91 32

Gastroenterologists 54 6 20 7

Cardiologist 49 6 23 8

Rheumatologist 37 4 18 6

Other internists 147 17 33 12

Psychiatrists 41 5 14 5

Neurologists 36 4 10 4

Gynecologists 34 4 0 0

Surgeons 12 1 12 4

Others 25 3 6 2

Unidentified 130 15 57 20

Major ICD-10 diagnosis

Irritable bowel syndrome 58 7 12 4

Anxiety disorder 52 6 19 7

Headache, NOS 52 6 15 5

Back pain, NOS 50 6 18 6

Insomnia 47 6 19 7

Migraine 30 4 * 2 1

Abdominal pain, NOS 26 3 11 4

Depression 21 2 9 3

Essential hypertension 20 2 17 6 **

Chest pain, NOS 20 2 8 3

Note. Mean age of female patients was 42 y (SD = 11), of male

patients was 43 (SD = 12).

([dagger]) Widowed patients were excluded in the analysis because of

the small sample size (females = 26, males = 4).

([double dagger]) Self-employed persons were included in employed


([section]) Includes physicians who registered as internal medicine

without further identification to the Board of Registration in

Medicine for Massachusetts.

NOS = not otherwise specified.

* p < .05 and ** p < .01, compared females and males, using chi-square



Somatic Symptoms of Married, Single, and Divorced/Separated Female and

Male Patients With Mind/Body Distress


Total Married Single Div/Sep

(n = 848) (n = 422) (n = 321) (n = 105)

Symptom (a) % % % %

Fatigue 70 ** 66 * 74 (#) 73

Insomnia 55 53 59 55

Headache 43 * 48 ** 43 40

Back pain 43 41 44 50

Joint or limb pain 40 36 43 ** 43

Abdominal pain 32 30 34 30

Shortness of breath 25 22 28 29

Palpitation 23 25 20 27

Constipation 23 ** 23 25 20

Chest pain 23 24 21 23

Nausea 20 ** 18 ** 24 (#) 17

Dizziness 19 18 22 20


Total Married Single Div/Sep

(n = 284) (n = 191) (n = 73) (n = 20)

Symptom (a) % % % %

Fatigue 61 57 71 70

Insomnia 51 47 58 70

Headache 37 35 44 35

Back pain 38 37 40 40

Joint or limb pain 35 37 27 45

Abdominal pain 38 39 30 55

Shortness of breath 24 21 33 25

Palpitation 19 19 16 25

Constipation 17 15 19 20

Chest pain 23 23 21 30

Nausea 12 10 19 10

Dizziness 16 15 19 20

Adjusted odds ratio (OR),

95% Confidence Interval (CI)

Women to men (a)

Symptom (a) OR CI

Fatigue 1.7 1.2, 2.4 ([dagger][dagger])

Insomnia 1.3 1.0, 1.8 ([dagger])

Headache 1.7 1.2, 2.3 ([dagger][dagger])

Back pain 1.6 1.2, 2.2 ([dagger][dagger])

Joint or limb pain 1.5 1.1, 2.1 ([dagger])

Abdominal pain 0.8 0.6, 1.1

Shortness of breath 1.3 0.9, 1.9

Palpitation 2.0 1.3, 3.0 ([dagger][dagger])

Constipation 1.9 1.3, 2.9 ([dagger][dagger])

Chest pain 1.3 0.9, 1.9

Nausea 2.2 1.4. 3.5 ([dagger][dagger])

Dizziness 1.6 1.1, 2.5 ([dagger])

Adjusted odds ratio (OR),

95% Confidence Interval (CI)

Single Div/Sep

to married (b) to married (b)

Symptom (a) OR CI OR CI

Fatigue 1.2 0.9, 1.7 1.3 0.8, 2.1

Insomnia 1.3 1.0, 1.8 1.2 0.8, 1.8


Headache 0.7 0.5, 1.1 0.7 0.4, 1.1

Back pain 1.0 0.8, 1.4 1.2 0.8, 1.9

Joint or limb pain 1.2 0.9, 1.7 1.2 0.8, 1.7

Abdominal pain 0.9 0.6, 1.2 1.1 0.7, 1.7

Shortness of breath 1.2 0.9, 1.7 1.6 1.0, 2.6


Palpitation 0.7 0.4, 1.0 1.3 0.8, 2.2

Constipation 0.9 0.7, 1.3 0.7 0.4, 1.2

Chest pain 0.8 0.6, 1.3 1.1 0.7, 1.8

Nausea 1.2 0.9, 1.8 0.8 0.5, 1.5

Dizziness 1.1 0.8, 1.7 1.3 0.8, 2.3

(a) Odds ratio adjusted for age (y), marital status (married, single,

and divorced/separated), education (-12/13+ y), employment (+/-),

SCL-90R depression (t score), and SCL-90R anxiety (t score), by

multiple logistic regression analysis.

(b) Odds ratio adjusted for age (y), sex (women and men), education

(- 12/13+ y), employment (+/-), SCL-90R depression (t score), and

SCL-90-R anxiety (t score), by multiple logistic regression analysis.

* p < .05 and ** p < .01, between women and men for each marital status

(total, married, single, and divorced/separated), chi-square tests.

(#) p < .05 among married, single, and divorced/separated patients for

each gender (women and men), chi-square test.

([dagger]) p < .05 and ([dagger][dagger]) p < .01, multiple

logistic regression analysis.


Gender Differences in the Total Number of Medical

Symptoms in the Total Sample (848 Women and 284

Men) and Patients With Each Major ICD-10 Diagnosis

Women Men


Total sample 4.2 2.8 ** 3.7 2.7

Major ICD-10 diagnoses

Irritable bowel syndrome 4.3 2.8 3.8 1.9

Anxiety disorder 4.5 2.9 4.6 2.9

Headache, NOS 3.7 2.7 3.8 2.8

Back pain, NOS 3.6 2.9 3.8 2.8

Insomnia 3.8 2.6 3.0 2.7

Migraine ([dagger]) 4.6 2.7 7.0

Abdominal pain, NOS 4.8 2.4 4.0 2.6

Depression 4.7 2.8 4.1 3.3

Essential hypertension 4.2 2.8 2.9 2.5

Chest pain, NOS 5.5 2.1 ** 2.2 1.9

Note. A total medical symptom score (0-12) was calculated by

summing the number of symptoms counted as positive. The number

of female and male patients with each ICD-10 diagnosis is shown

in Table 1.

([dagger]) Two male patients had migraine (total medical symptom scores

5 and 9); because of the small sample size, the analysis of covariances

was not used between women and men.

** p < .01, comparing women with men, analysis of covariances

adjusted for the effects of age.


Predictors of Total Number of Medical Symptoms in

Patients With Mind/Body Distress: Results of Multiple

Regression Analysis (n = 1,132)

Unstandardized Standardized

regression regression

Variable coefficient SE coefficient

Anxiety (t score) .042 .011 .158 **

Sex (F = 1, M = 0) .905 .205 .140 **


(t score) .042 .013 .137 **

Age (y) -.020 .008 -.085 *

Education ([greater than or

equal to] 13 = 1, [less than

or equal to] 12 = 0) -.416 .281 -.045


(employed = 1,

unemployed = 0) -.113 .253 -.014

Marital status *

Single .048 .197 .008

Divorced/separated .222 .277 .025

Note. A total medical symptom score (0-12) was calculated by

summing the number of symptoms counted as positive.

* Married patients were chosen as a reference group (Single = 1, not

single = 0; divorced/separated = 1, not divorced/separated = 0).

* p < .05 and ** p < .01, multiple regression analysis.


Scores of Symptom Checklist-90R and Stress Perception in Female and

Male Patients With Mind/Body Distress


(n = 848)


Raw scores scores


Symptom Checklist-90R

Somatization 22 14 ** 60 9

Obsessive-compulsiveness 31 20 ** 63 9

Interpersonal sensitivity 23 16 ** 62 9

Depression 34 19 ** 64 8

Anxiety 29 19 ** 64 10

Hostility 18 16 58 9

Phobic anxiety 9 13 55 11

Paranoid ideation 16 16 57 11

Psychoticism 11 10 62 10

Global severity index 23 13 ** 64 8

Stress perception

Work 6.9 2.8

Family 6.2 2.7 **

Social 4.4 2.7

Financial 5.9 3.0

Health 7.0 2.7 **

Living situation 4.5 3.0 *

Neighborhood 2.3 2.2


(n = 284)

Raw scores t scores


Symptom Checklist-90R

Somatization 19 13 62 11 **

Obsessive-compulsiveness 25 14 66 11 **

Interpersonal sensitivity 17 12 65 12 **

Depression 23 13 69 11 **

Anxiety 21 12 70 11 **

Hostility 19 16 61 10 **

Phobic anxiety 8 11 59 12 **

Paranoid ideation 19 17 58 12

Psychoticism 14 15 63 11

Global severity index 18 9 69 10 **

Stress perception

Work 7.5 2.7 **

Family 5.6 2.7

Social 4.1 2.7

Financial 5.6 3.0

Health 6.3 2.8

Living situation 4.0 2.9

Neighborhood 2.4 2.3

Note. T scores on the Symptom Checklist-90R scales in a female general

population and in a male general population. The t scores were based

on the gender-appropriate norms, separated for women and men,

and were standardized using the data from the US general population.

* p < .05 and ** p < .01, compared women with men;

analysis of covariances adjusted for the effects of age.


Differences in Symptom Checklist-90R and Perception of Stress Among

Married, Single, and Divorced/Separated Male and Female Patients

With Mind/Body Distress: Results of Analyses of Covariances


Married Single Div/sep

(n = 422) (n = 321) (n = 105)


Symptom Checklist-90R

Somatization 21 14 23 14 23 14

Obsessive-compulsiveness 28 19 34 21 34 21

Interpersonal sensitivity 21 15 26 17 23 17

Depression 31 18 37 20 38 19

Anxiety 27 18 31 21 28 20

Hostility 17 16 18 16 17 17

Phobic anxiety 8 13 9 12 10 14

Paranoid ideation 15 15 18 17 17 18

Psychoticism 10 9 12 11 13 11

Global severity index 22 12 25 14 24 12

Perception of Stress

Work 6.5 2.9 7.3 2.6 6.8 3.1

Family 6.3 2.6 6.0 2.7 6.5 3.0

Social 4.0 2.7 4.9 2.6 4.3 2.9

Financial 5.5 3.0 6.1 3.0 7.2 2.9

Health 7.0 2.7 6.9 2.7 7.2 2.8

Living situation 4.1 3.0 4.6 2.9 5.9 3.3

Neighborhood 2.2 2.1 2.5 2.3 2.3 2.6


Married Single Div/sep

(n = 191) (n = 73) (n = 20)


Symptom Checklist-90R

Somatization 18 12 20 15 25 12

Obsessive-compulsiveness 23 14 29 15 31 12

Interpersonal sensitivity 16 12 18 11 18 13

Depression 22 13 26 13 27 13

Anxiety 20 12 24 12 19 12

Hostility 19 16 19 15 20 16

Phobic anxiety 7 10 10 13 10 11

Paranoid ideation 16 16 23 19 26 19

Psychoticism 12 13 19 18 18 14

Global severity index 17 9 20 9 19 7

Perception of Stress

Work 7.5 2.4 7.4 3.0 8.0 2.8

Family 5.6 2.5 5.7 3.0 5.6 3.2

Social 3.8 2.5 4.5 2.9 4.3 3.1

Financial 5.5 2.9 6.1 3.1 4.2 3.1

Health 6.0 2.7 6.6 2.8 6.9 3.0

Living situation 3.4 2.7 5.0 2.9 4.5 3.7

Neighborhood 2.3 2.2 2.7 2.7 1.8 0.6


Marital Sex x Co-

Sex status married varying

(df = 1) (df = 2) (df = 2) age

Symptom Checklist-90R

Somatization 3.9 * 2.5 1.1 8.9 **

Obsessive-compulsiveness 12.0 ** 8.6 ** 0.2 5.8 *

Interpersonal sensitivity 18.7 ** 2.7 1.1 40.1 **

Depression 45.3 ** 9.1 ** 0.1 13.8 **

Anxiety 21.9 ** 1.1 0.1 10.6 **

Hostility 2.7 1.5 0.4 49.7 **

Phobic anxiety 0.1 1.4 0.4 13.3 **

Paranoid ideation 6.4 * 3.9 * 1.6 17.1 **

Psychoticism 17.1 ** 7.9 ** 2.7 16.2 **

Global severity index 22.3 ** 3.5 * 0.2 25.0 **

Perception of Stress

Work 9.3 ** 0.5 1.4 37.3 **

Family 5.9 * 1.2 0.3 1.6

Social 0.8 2.9 * 0.1 12.1 **

Financial 0.5 6.2 ** 4.7 ** 12.1 **

Health 7.4 ** 0.9 0.9 5.8 *

Living situation 1.6 11.6 ** 2.3 0.8

Neighborhood 0.4 1.2 0.3 0.4

Analysis of covariances controlling for the effects of sex (women

and men), marital status (married, single, and divorced/separated),

and age.

* p < .05; ** p < .01.


We wish to thank Margaret Baim, RN, MS, CS; Carol Lynn Mandle, PhD, RN, CS; Cynthia Medich, PhD, RN; Carol L Wells-Federman, RN, MEd, CS; Patricia Martin Arcari, PhD, RN; and Margaret Ennis, MA, LMHC, of the clinical staff of the Mind/Body Medical Institute, Beth Israel Deaconess Center, for their help in data collection.


For further information, please address correspondence to Mutsuhiro Nakao, Mind/Body Medical Institute, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA 02215, USA (e-mail: mnakao@bidmc.harvard.edu). After April 1, 2001, address comments and queries to Mutsuhiro Nakao, MD, Teikyo University Center for Evidence-Based Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, Japan (e-mail: aaaa-tky@umin.ac.jp).


(1.) Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and adequacy of therapy. Arch Intern Med. 1990;150:1685-1689.

(2.) Brown JW, Roberson LS, Kosa J, Alpert JJ. A study of general practice in Massachusetts. JAMA. 1971;216:301-306.

(3.) Hahn SR, Thompson KS, Wills TA, et al. The difficult doctor-patient relationship: Somatization, personality, and psychopathology. J Clin Epidemiol. 1994;47:647-657.

(4.) Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11:1-6.

(5.) Katon W, Kleinman A, Rosen G. Depression and somatization: A review. Am J Med. 1982;72:127-135,241-247.

(6.) Wool CA, Barsky AJ. Do women somatize more than men? Gender differences in somatization. Psychosomatics. 1994; 35:445-452.

(7.) Gijsbers van Wijk CMT, Kolk AM. Sex differences in physical symptoms: The contribution of symptom perception theory. Soc Sci Med. 1997;45:231-246.

(8.) Kroenke K, Spitzer RL. Gender differences in the reporting of physical and somatoform symptoms. Psychosom Med. 1998;60:150-155.

(9.) Piccinelli M, Simon G. Gender and cross-cultural differences in somatic symptoms associated with emotional distress. An international study in primary care. Psychol Med. 1997; 27:433-444.

(10.) Lipsitt DR. The painful woman: Complaints, symptoms, and illness. In: Notman MT, Nadelson CC, eds. The Woman Patient. vol 3. New York: Plenum; 1982.

(11.) Lewis CE, Lewis MA, Lorimer A. The use of school nurturing services by children in an `adult-free’ system. Pediatrics. 1977;60:499-507.

(12.) Verbrugge LM. Gender and health: An update on hypotheses and evidence. J Health Soc Behav. 1985;26:157-177.

(13.) Katon W, Kleinman A, Rosen G. Depression and somatization: Part 1, a review. Am J Med. 1982;72:127-135.

(14.) Crowe RR, Noyes R, Pauls DL. A family study of panic disorder. Arch Gen Psychiatry. 1983;40:1065-1069.

(15.) Barett JE, Barrett JA, Oxman TE, et al. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry. 1988;45:1100-1106.

(16.) Regier DA, Boyd JH, Burke JD, et al. One-month prevalence of mental disorders in the United States. Arch Gen Psychiatry. 1988;45:977-986.

(17.) Orenstein H. Briquet’s syndrome in association with depression and panic Prevalence by self-report questionnaire and recognition by nonpsychiatric physicians. Arch Gen Psychiatry. 1980;37:999-1004.

(18.) Kandel DB, Davies M, Raveis VH. The stressfulness of daily social roles for women: Marital, occupational and household roles. J Health Soc Behav. 1985;26:64-78.

(19.) Pennebaker JW, Brittingham GL. Environmental and sensory cues affecting the perception of physical symptoms. In: Baum A, Singer JE, eds. Advances in Environmental Psychology: Environmental Health. Hillsdale, NJ: Erlbaum; 1982.

(20.) Barsky AJ, Goodson JD, Lane RS, Cleary PD. The amplication of somatic symptoms. Psychosom Med. 1988;50:510-519.

(21.) Barsky AJ. Amplification, somatization, and the somatoform disorders. Psychosomatics. 1992;33:28-34.

(22.) Hammond EC. Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women. Am J Public Health. 1964;54:11-23.

(23.) Escobar JI, Burnam A, Karno M, et al. Somatization in the community. Arch Gen Psychiatry. 1987;44:713-718.

(24.) Kroenke K, Price RK. Symptoms in the community: Prevalence, classification, and psychiatric comorbidity. Arch Intern Med. 1993;153:2474-2480.

(25.) Verbrugge LM. Marital status and health. Journal of Marriage & the Family. 1979;41:267-285.

(26.) Burman B, Margolin G. Analysis of the association between marital relationships and health problems: An interactional perspective. Psychol Bull. 1992;112:39-63.

(27.) Smith KR, Waitzman NJ. Double jeopardy: Interaction effects of marital and poverty status on the risk of mortality. Demography. 1994;31:487-507.

(28.) Waldron I, Hughes ME, Brooks TL. Marriage protection and marriage selection–Prospective evidence for reciprocal effects of marital status and health. Soc Sci Med. 1996; 43:113-123.

(29.) Benson H, Stuart E. The Wellness Book. New York: Carol; 1992.

(30.) World Health Organization. ICD-10 International Statistical Classification of Diseases and Related Health Problems. 10th revis, vol 1. Tabular List. Geneva: WHO; 1992.

(31.) Derogatis LR. The SCL-90-R. Baltimore: Clinical Psychometric Research; 1977.

(32.) Derogatis LR, Rickels K, Rock A. The SCL-90 and the MMPI: A step in the validation of a new self-report scale. Brit J Psychiatry. 1976;280-289.

(33.) Derogatis LR. The SCL-90-R: Administration Scoring and Procedures Manual II. Baltimore: Clinical Psychometric Research; 1992.

(34.) SAS/IMS User’s Guide, Release 6.03 Edition. Cary, NC: SAS Institute; 1988.

(35.) Nathanson CA. Sex, illness and medical care: A review of data, theory and method. Soc Sci Med. 1977;1:13-26.

(36.) Tousignant M, Brosseau R, Tremblay L. Sex biases in mental health scales: Do women tend to report less serious symptoms and confide more than men? Psychol Med. 1987;17:203-215.

(37.) Mechanic D. The experience and expression of distress: The study of illness behavior and medical utilization. In: Mechanic D, ed. Handbook of Health Care and the Health Professions. New York: Free Press; 1983:591-607.

(38.) Anson O, Anson J. Women’s health and labour force status: An enquiry using a multiple point measure of labour force participation. Soc Sci Med. 1987;25:57-63.

(39.) Gove WR, Hughes M. Possible causes of the apparent sex differences in physical health: An empirical investigation. American Sociology Review. 1979;44:126-146.

(40.) Kirn J, Lembroso PJ. Development of the cerebral cortex: XI, Sexual dimorphism in the brain. J Am Acad Child Adolesc Psychiatry. 1998;37:1228-1230.

(41.) Fitch RH, Denenberg VH. A role for ovarian hormones in sexual differentiation of the brain. Behav Brain Sci. 1998; 21:311-327.

(42.) Verbrugge LM, Wingard DL. Sex differentials in health and mortality. Women Health. 1987;12:103-145.

(43.) Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98:310-357.

(44.) Berkman LF, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol. 1979;109:186-204.

Dr Nakao is with the Mind/Body Medical Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, and the Department of Internal Medicine, School of Medicine, Teikyo University in Japan. Dr Fricchione, Ms Zuttermeister, Ms Myers, and Dr Benson are also with the Mind/Body Medical Institute. Drs Fricchione and Barsky are with the Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston. Dr Fricchione is also with the Carter Center Mental Health Program in Atlanta.

COPYRIGHT 2001 Heldref Publications

COPYRIGHT 2002 Gale Group