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Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices

Published online by Cambridge University Press:  31 August 2011

R. E. Taylor ,
T. Marshall ,
A. Mann  and
D. P. Goldberg
R. E. Taylor*
Affiliation:
Barts and the London School of Medicine and Dentistry, Queen Mary, Charterhouse Square, London, UK
T. Marshall
Affiliation:
London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
A. Mann
Affiliation:
Institute of Psychiatry, De Crespigny Park, London, UK
D. P. Goldberg
Affiliation:
Institute of Psychiatry, De Crespigny Park, London, UK
*
*Address for correspondence: R. E. Taylor, Ph.D., Barts and the London School of Medicine and Dentistry, Queen Mary, Centre for Psychiatry, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK. (Email: [email protected])
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Abstract

Background

In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor–patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment.

Method

We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate.

Results

Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79–5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23–33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05–3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67–33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented.

Conclusions

Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

Keywords

Attachment styledoctor–patient relationshipfrequent attendersmedically unexplained symptomsprimary care
Type
Original Articles
Information
Psychological Medicine , Volume 42 , Issue 4 , April 2012 , pp. 855 - 864
Copyright
Copyright © Cambridge University Press 2011

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References

Bridges, K, Goldberg, D, Evans, B, Sharpe, T (1991). Determinants of somatization in primary care. Psychological Medicine 21, 473–483.CrossRefGoogle ScholarPubMed
Browne, GB, Humphrey, B, Pallister, R, Browne, JA, Shetzer, L (1982). Prevalence and characteristics of frequent attenders in a prepaid Canadian family practice. Journal of Family Practice 14, 63–71.Google Scholar
Ciechanowski, PS, Walker, EA, Katon, WJ, Russo, JE (2002). Attachment theory: a model for health care utilization and somatization. Psychosomatic Medicine 64, 660–667.Google Scholar
Cook, TD (2002). Advanced statistics: up with odds ratios! A case for odds ratios when outcomes are common. Academic Emergency Medicine 9, 1430–1434.CrossRefGoogle ScholarPubMed
Corney, R, Murray, J (1988). The characteristics of high and low attenders at two general practices. Social Psychiatry and Psychiatric Epidemiology 23, 39–48.CrossRefGoogle ScholarPubMed
Craig, TK, Boardman, AP, Mills, K, Daly-Jones, O, Drake, H (1993). The South London Somatisation Study. I: Longitudinal course and the influence of early life experiences. British Journal of Psychiatry 163, 579–588.CrossRefGoogle Scholar
Craig, TK, Drake, H, Mills, K, Boardman, AP (1994). The South London Somatisation Study. II. Influence of stressful life events and secondary gain. British Journal of Psychiatry 165, 248–258.CrossRefGoogle ScholarPubMed
De Waal, M, Arnold, I, Eekhof, J (2004). Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. British Journal of Psychiatry 184, 470–476.CrossRefGoogle ScholarPubMed
Derogatis, LR, Melisaratos, N (1983). The Brief Symptom Inventory: an introductory report. Psychological Medicine 13, 596–605.CrossRefGoogle ScholarPubMed
Gittleman, MG, Klein, MH, Smidler, NA, Essex, M (1998). Recollections of parental behaviour, adult attatchment and mental health: mediating and moderating effects. Psychological Medicine 28, 1443–1455.CrossRefGoogle Scholar
Goldberg, D, Williams, P (1988). A User's Guide to the General Health Questionnaire. NFER-Nelson: Windsor.Google Scholar
Goldberg, DP, Bridges, K (1988). Somatic presentations of psychiatric illness in primary care setting. Journal of Psychosomatic Research 32, 137–144.CrossRefGoogle ScholarPubMed
Hahn, SR, Kroenke, K, Spitzer, RL, Brody, D, Williams, JB, Linzer, M, deGruy, FV 3rd (1996). The difficult patient: prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine 11, 1–8.CrossRefGoogle ScholarPubMed
Hanel, G, Henningsen, P, Herzog, W, Sauer, N, Schaefert, R, Szecsenyi, J, Löwe, B (2009). Depression, anxiety, and somatoform disorders: vague or distinct categories in primary care? Results from a large cross-sectional study. Journal of Psychosomatic Research 67, 189–197.CrossRefGoogle ScholarPubMed
Hazan, C, Shaver, P (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology 52, 511–524.CrossRefGoogle ScholarPubMed
Heywood, PL, Blackie, GC, Cameron, IH, Dowell, AC (1998). An assessment of the attributes of frequent attenders to general practice. Journal of Family Practice 15, 198–204.CrossRefGoogle ScholarPubMed
Hunter, JJ, Maunder, RG (2001). Using attachment theory to understand illness behaviour. General Hospital Psychiatry 23, 177–182.CrossRefGoogle Scholar
Jenkinson, C, Layte, R, Wright, L, Coulter, A (1996). The U.K. SF-36: An Analysis and Interpretation Manual. Health Services Research Unit: Oxford.Google Scholar
Jyvasjarvi, S, Joukamaa, M, Vaisanen, E, Larivaara, P, Kivelä, S, Keinänen-Kiukaanniemi, S (2001). Somatizing frequent attenders in primary health care. Journal of Psychosomatic Research 50, 185–192.CrossRefGoogle ScholarPubMed
Karlsson, H, Joukamaa, M, Lahti, I (1997). Frequent attender profiles: different clinical subgroups among frequent attender patients in primary care. Journal of Psychosomatic Research 42, 157–166.CrossRefGoogle ScholarPubMed
Karlsson, H, Lehtinen, V, Joukamaa, M (1994). Frequent attenders of Finnish public primary health care: sociodemographic characteristics and physical morbidity. Journal of Family Practice 11, 424–430.CrossRefGoogle ScholarPubMed
Karlsson, H, Lehtinen, V, Joukamaa, M (1995). Are frequent attenders of primary health care distressed? Scandinavian Journal of Primary Health Care 13, 32–38.CrossRefGoogle ScholarPubMed
Katon, W, Von Korff, M, Lin, E, Lipscomb, P, Russo, J, Wagner, E, Polk, E (1990). Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. General Hospital Psychiatry 12, 355–362.CrossRefGoogle ScholarPubMed
Lin, EH, Katon, W, Von Korff, M, Bush, T, Lipscomb, P, Russo, J, Wagner, E (1991). Frustrating patients: physician and patient perspectives among distressed high users of medical services. Journal of General Internal Medicine 6, 241–246.CrossRefGoogle ScholarPubMed
Lloyd, KR, Jacob, KS, Patel, V, St Louis, L, Bhugra, D, Mann, AH (1998). The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders. Psychological Medicine 28, 1231–1237.CrossRefGoogle ScholarPubMed
Maunder, RG, Hunter, JJ (2001). Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosomatic Medicine 63, 556–567.CrossRefGoogle ScholarPubMed
McCormick, A, Fleming, D, Charlton, J (1995). Morbidity Statistics from General Practice: Fourth National Study 1991–1992, pp. 24–31. HMSO: London.Google Scholar
Mickelson, KD, Kessler, RC, Shaver, PR (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology 73, 1092–1106.CrossRefGoogle Scholar
Morriss, R, 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 ScholarPubMed
Portegijs, PJ, van der Horst, FG, Proot, IM, Kraan, HF, Gunther, NC, Knottnerus, JA (1996). Somatization in frequent attenders of general practice. Social Psychiatry and Psychiatric Epidemiology 31, 29–37.CrossRefGoogle ScholarPubMed
Robinson, JO, Granfield, AJ (1986). The frequent consulter in primary medical care. Journal of Psychosomatic Research 30, 589–600.CrossRefGoogle ScholarPubMed
Scaife, B, Gill, P, Heywood, P, Neal, R (2000). Socio-economic characteristics of adult frequent attenders in general practice: secondary analysis of data. Family Practice 17, 298–304.CrossRefGoogle ScholarPubMed
Stein, H, Jacobs, NJ, Ferguson, KS, Allen, JG, Fonagy, P (1998). What do adult attachment scales measure? Bulletin of the Menninger Clinic 62, 33–82.Google ScholarPubMed
Taylor, RE, Mann, AH (1999). Somatisation in primary care. Journal of Psychosomatic Research 47, 61–66.Google ScholarPubMed
Taylor, RE, Mann, AH, White, NJ, Goldberg, DP (2000). Attachment style in patients with unexplained physical complaints. Psychological Medicine 30, 931–941.CrossRefGoogle ScholarPubMed
Thompson, D, Ciechanowski, PS (2003). Attaching a new understanding to the patient–physician relationship in family practice. Journal of the American Board of Family Practice 16, 219–226.CrossRefGoogle Scholar