Hostname: page-component-586b7cd67f-t7czq Total loading time: 0 Render date: 2024-11-23T05:03:05.808Z Has data issue: false hasContentIssue false
  • English
  • Français

Randomized trial of reattribution on psychosocial talk between doctors and patients with medically unexplained symptoms

Published online by Cambridge University Press:  02 July 2009

R. Morriss ,
L. Gask ,
C. Dowrick ,
G. Dunn ,
S. Peters ,
A. Ring ,
J. Davies  and
P. Salmon
R. Morriss*
Affiliation:
Division of Psychiatry, School of Community Health Sciences, University of Nottingham, Queen's Medical School, Nottingham, UK
L. Gask
Affiliation:
National Primary Care Research and Development Centre, University of Manchester, UK
C. Dowrick
Affiliation:
Division of Primary Care, School of Behavioural, Community and Population Science, University of Liverpool, UK
G. Dunn
Affiliation:
Division of Epidemiology and Health Sciences, University of Manchester, UK
S. Peters
Affiliation:
Division of Psychology, School of Psychological Sciences, University of Manchester, UK
A. Ring
Affiliation:
Division of Primary Care, School of Behavioural, Community and Population Science, University of Liverpool, UK
J. Davies
Affiliation:
Computing Services Department, University of Liverpool, UK
P. Salmon
Affiliation:
Division of Clinical Psychology, School of Population, Community and Behavioural Sciences, University of Liverpool, UK
*
*Address for correspondence: R. Morriss, Professor of Psychiatry and Community Mental Health, Division of Psychiatry, School of Community Health Sciences, University of Nottingham, South Block, A Floor, Queen's Medical School, Nottingham NG7 2UH, UK. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

In reattribution, general practitioners (GPs) request psychosocial information directly and explain medically unexplained symptoms (MUS) using psychosocial information in the consultation. We explored whether reattribution training (RT) increased the communication of psychosocial information and decreased communication about somatic intervention between GPs and their MUS patients.

Method

A cluster randomized controlled trial (RCT) of RT versus usual treatment in GPs from 16 practices and 141 patients with MUS on audio-recorded and transcribed doctor–patient communication in an index consultation. In a secondary data analysis, the Liverpool Clinical Interaction Analysis Scheme (LCIAS) was applied by an experienced rater to each turn of speech in the transcript from the index consultation blind to treatment allocation.

Results

After RT, patients were more likely to disclose and discuss psychosocial problems, and propose psychosocial explanations for symptoms; around 25% of patients discussed psychosocial information extensively. In the RT group, GPs did not seek new psychosocial disclosure but they reduced advocacy for somatic intervention. After RT, GPs suggested, on average, two utterances of psychosocial explanation and six utterances of somatic intervention.

Conclusions

After RT, some patients discussed psychosocial issues extensively but GPs did not probe underlying psychosocial issues. They gave mixed psychosocial and somatic messages about MUS, which may have increased patients' concerns about their health. GPs should actively seek the disclosure of underlying psychosocial problems and give clear, unambiguous messages to MUS patients when they are willing to discuss psychosocial issues.

Keywords

Communication barriersprimary health caresomatoform disorders
Type
Original Articles
Information
Psychological Medicine , Volume 40 , Issue 2 , February 2010 , pp. 325 - 333
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Barsky, AJ, Orav, EJ, Bates, DW (2005). Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives of General Psychiatry 62, 903–910.CrossRefGoogle Scholar
Blankenstein, AH (2001). Somatising patients in general practice reattribution, a promising approach. Ph.D. thesis, Vrije Universiteit, The Netherlands.Google Scholar
Bridges, K, Goldberg, D, Evans, B, Sharpe, T (1991). Determinants of somatisation in primary care. Psychological Medicine 21, 473–483.CrossRefGoogle Scholar
Coia, P, Morley, S (1998). Medical reassurance and patients' responses. Journal of Psychosomatic Research 45, 377–386.Google Scholar
EuroQol Group (1990). EuroQol – a new facility for the measurement of health-related quality of life. Health Policy 16, 199–208.CrossRefGoogle Scholar
Frostholm, L, Fink, P, Oernboel, E, Christensen, KS, Toft, T, Olesen, F (2005). The uncertain consultation and patient satisfaction: the impact of patients' illness perceptions and a randomized controlled trial on the training of physicians' communication skills. Psychosomatic Medicine 67, 897–905.CrossRefGoogle Scholar
Goldberg, D, Gask, L, O'Dowd, T (1989). The treatment of somatisation: teaching techniques of reattribution. Journal of Psychosomatic Research 33, 689–695.CrossRefGoogle Scholar
Huibers, MJ, Beurskens, AJ, Bleijenberg, G, van Schayck, CP (2007). Psychosocial interventions by general practitioners. Cochrane Database of Systematic Reviews 3, CD003494.Google Scholar
Kaaya, S, Goldberg, D, Gask, L (1992). Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners. Medical Education 26, 138–144.CrossRefGoogle Scholar
Kirmayer, LJ, Robbins, JM (1996). Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychological Medicine 26, 937–951.CrossRefGoogle Scholar
Larisch, A, Schweickhardt, A, Wirsching, M, Fritzsche, K (2004). Psychosocial interventions for somatizing patients by the general practitioner: a randomized controlled trial. Journal of Psychosomatic Research 57, 507–514.CrossRefGoogle Scholar
Morriss, R, Dowrick, C, Salmon, P, Peters, S, Dunn, G, Rogers, A, Lewis, B, Charles-Jones, H, Hogg, J, Clifford, R, Rigby, C, Gask, L (2007). Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. British Journal of Psychiatry 191, 536–542.CrossRefGoogle Scholar
Morriss, R, Dowrick, C, Salmon, P, Peters, S, Rogers, A, Dunn, G (2006). Turning theory into practice: rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (the MUST). General Hospital Psychiatry 28, 343–351.CrossRefGoogle Scholar
Morriss, RK, Gask, L (2002). Treatment of patients with somatized mental disorder: effects of reattribution training on outcomes under the direct control of the family doctor. Psychosomatics 43, 394–399.CrossRefGoogle ScholarPubMed
Morriss, RK, Gask, L, Ronalds, C, Downes-Grainger, E, Thompson, H, Goldberg, D (1999). Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. British Journal of General Practice 49, 263–267.Google Scholar
Morriss, RK, Gask, L, Ronalds, C, Downes-Grainger, E, Thompson, H, Leese, B, Goldberg, D (1998). Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Family Practice 15, 119–125.CrossRefGoogle Scholar
Peters, S, Rogers, A, Salmon, P, Gask, L, Dowrick, C, Towey, M, Clifford, R, Morriss, R (2009). What do patients choose to tell their doctors? Qualitative analysis of potential barriers to reattributing medically unexplained symptoms. Journal of General Internal Medicine 24, 540–542.CrossRefGoogle Scholar
Peveler, R, Kilkenny, L, Kinmonth, AL (1997). Medically unexplained symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. Journal of Psychosomatic Research 42, 245–252.CrossRefGoogle Scholar
Ring, A, Dowrick, CF, Humphris, GM, Davies, J, Salmon, P (2005). The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Social Science in Medicine 61, 1505–1515.CrossRefGoogle Scholar
Rosendal, M, Bro, F, Sokolowski, I, Fink, P, Toft, T, Olesen, F (2005). A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs' attitudes. Family Practice 22, 419–427.CrossRefGoogle Scholar
Rosendal, M, Olesen, F, Fink, P, Toft, T, Sokolowski, I, Bro, F (2007). A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on patient outcome. General Hospital Psychiatry 29, 364–373.CrossRefGoogle Scholar
Salmon, P, Dowrick, CF, Ring, A, Humprhis, GM (2004). Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with medically unexplained symptoms present to general practitioners. British Journal of General Practice 54, 171–176.Google Scholar
Salmon, P, Humphris, GM, Ring, A, Davies, JC, Dowrick, CF (2006). Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure. Psychosomatic Medicine 68, 570–577.CrossRefGoogle Scholar
Salmon, P, Humphris, GM, Ring, A, Davies, JC, Dowrick, CF (2007). Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention. Psychosomatic Medicine 69, 571–577.CrossRefGoogle Scholar
StataCorp (2003). Stata Statistical Software: Release 8.0. Stata Corporation: College Station, TX.Google Scholar
van Ravesteijn, HJ, Lucassen, PLBJ, olde Hartmann, TC (2008). Reattribution for medically unexplained symptoms. British Journal of Psychiatry 192, 314–315; authors' reply 315.CrossRefGoogle Scholar