Communication Study
Medically unexplained symptoms as a threat to patients’ identity?: A conversation analysis of patients’ reactions to psychosomatic attributions

https://doi.org/10.1016/j.pec.2009.09.043Get rights and content

Abstract

Objective

Interactions between patients suffering from medically unexplained symptoms (MUS) and their physicians are usually perceived as difficult and unsatisfactory by both parties. In this qualitative study, patients’ reactions to psychosomatic attributions were analyzed on a micro-level.

Methods

144 consultations between consultation-and-liaison (CL) psychotherapists and inpatients with MUS, who were treated according to a modified reattribution model, were recorded. Linguists and psychologists evaluated these consultations by applying conversation and positioning analysis.

Results

When introducing a psychosomatic attribution, therapists use discursive strategies to exert interactional pressure on the patient; while simultaneously using careful and implicit formulations. Three linguistic patterns could be found in which patients subtly refute, drop or undermine the psychosomatic attribution in their reply. Moreover, in this context patients position themselves as somatically ill or justify their own life situation.

Conclusion

The results suggest that patients interpret psychosomatic attributions and even subtle suggestions from the psychotherapists as face-threatening ‘other-positionings’.

Practice implications

When implementing the reattribution model, it should be taken into account that interactional resistance might be a necessary step in the process of the patient's understanding. Nevertheless therapists should introduce reattribution in a patient-centered rather than persuasive way and they should openly address patients’ fears of being stigmatized.

Introduction

International studies show that 10–20% of patients in primary care suffer from physical symptoms without any sufficient organic findings [1], [2]. In some medical specialties, such as gynaecology, neurology, or gastroenterology, in 30–70% of cases no organic causes for the patients’ symptoms can be found [3], [4], [5]. These patients with medically unexplained symptoms (MUS) constitute an economically relevant group in the health care system [6], since they receive many elaborate diagnostic examinations and medical interventions, in spite of the absence of an organic disease [6], [7], [8], [9], [10]. These interventions can contribute to a somatic fixation [11]; therefore, the risk of iatrogenic damage is also discussed in the context of MUS [6], [12], [13], [14].

The parties involved – both physicians and patients – often experience their consultations as unsatisfactory and stressful. Physicians often harbor a negative attitude towards MUS patients or feel overstrained by the task of attending to them [15], [16], [17], [18]. Patients feel that they are not being taken seriously by the physicians and that the reality of their symptoms is being questioned [19], [20], [21], [22], [23]. Patients and physicians describe consultations as being fraught with misunderstandings and mutual doubts [24].

Literature regarding the interaction with MUS patients shows inconsistent and sometimes contradictory results. Some studies show that physicians often follow a psychogenic understanding of MUS while patients pursue a somatic illness model [17], [24]. Other studies show that MUS patients do give (certain) hints about psychosocial stress, and they are more likely to hope for emotional support from their general practitioner than other patients [25], [26], [27]. Physicians, however, often ignore these hints and prescribe further somatic interventions [25], [28] or may react even less empathetically to patients with MUS than to patients whose symptoms are medically explicable [29]. If, on the other hand, patients are given the opportunity to talk openly about their psychosocial stress, the likelihood that consultations will end in somatic interventions decreases [30], [31]. Studies suggest that the involved parties often talk at cross-purposes regarding the patient's symptoms: While physicians often refer to visible findings and test results, patients claim to have the authority of privileged access to the perception of their own body and pain [24], [32]. The reported studies on interaction with MUS patients were conducted in different settings (primary care and specialist clinics) and used mostly content-oriented methods or coding schemes [25], [26], [27], [28], [29], [30], [31]. Until now systematic microanalytical studies – i.e. studies that take into account the sequential unfolding and detailed phenomena of the interaction – with MUS patients have been lacking.

The situation of MUS patients in general hospitals is particularly delicate: when patients are told that they will soon be released from the hospital since “nothing” could be found – despite persisting symptoms – this leads to a precarious state for both the patients and the medical system. In an interdisciplinary project at the Department of German Philology (Linguistics) and the Department of Psychosomatic Medicine, psychotherapeutic interventions with MUS inpatients within the framework of the psychosomatic consultation-and-liaison (CL) service were analyzed on a micro-level using conversation analysis [33]. The objective of this analysis was to gain a more differentiated insight into the conversational dynamics between patients and therapists and to identify specific communication patterns. Specifically, the goal of this paper was to analyze how patients take up ‘psychosomatic attributions’ introduced by the therapists.

Section snippets

Sample

The consultations analyzed here were conducted and recorded for a study of the CL-service of the University Hospital Freiburg in which the effects of short-term psychotherapeutic interventions for somatizing patients in the general hospital were investigated [34]. Patients without organic findings (mostly in internal medicine and neurology) who met the criteria for somatization [35], [36] and consented to participate were included in the study (n = 91). These patients were randomly assigned to an

Results

We focus on the patients’ reactions to – as we call them – ‘psychosomatic attributions’ made by the psychotherapists. Since the reactions depend on the character of the attributions, we will first outline these attributions before taking a closer look at the patients’ reactions.

Discussion

These micro-level analyses of consultations between psychotherapists and MUS patients in a general hospital focussed on patients’ immediate reactions to psychosomatic attributions proposed by their therapists. When introducing a psychosomatic attribution, therapists use different discursive strategies to exert interactional pressure on the patient; while on the content level they often employ careful and sometimes implicit formulations and modalizations.

Three linguistic interactional patterns

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