Communication StudyMedically unexplained symptoms as a threat to patients’ identity?: A conversation analysis of patients’ reactions to psychosomatic attributions
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
References (85)
- et al.
Medically unexplained physical symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion
J Psychosom Res
(1997) - et al.
Medically unexplained symptoms: an epidemiological study in seven specialities
J Psychosom Res
(2001) Surgery and medical treatment in persistent somatizing patients
J Psychosom Res
(1992)- et al.
Somatic fixation: the harm of healing
Soc Sci Med
(2003) - et al.
A comparative study of iatrogenesis, medication abuse, and psychiatric morbidity in chronic pain patients with and without medically explained symptoms
Pain
(1998) - et al.
Unexplained symptoms in primary care: perspectives of doctors and patients
Gen Hosp Psychiatry
(2000) - et al.
Understanding the narratives of people who live with medically unexplained illness
Patient Educ Couns
(2005) ‘I just want permission to be ill’: towards a sociology of medically unexplained symptoms
Soc Sci Med
(2006)- et al.
It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors
Soc Sci Med
(2003) - et al.
‘I am not the kind of woman who complains of everything’: illness stories on self and shame in women with chronic pain
Soc Sci Med
(2004)
Constructions of chronic pain in doctor–patient relationships: bridging the communication chasm
Patient Educ Couns
Patients with medically unexplained symptoms: sources of patients’ authority and implications for demands on medical care
Soc Sci Med
The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms
Soc Sci Med
The power of the visible: the meaning of diagnostic tests in chronic back pain
Soc Sci Med
The treatment of somatization: teaching techniques of reattribution
J Psychosom Res
Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation
Patient Educ Couns
Psychosocial interventions for somatizing patients by the general practitioner: a randomized controlled trial
J Psychosom Res
A randomized controlled trial of brief training in the assessment and treatment of somatisation in primary care: effects on patient outcome
Gen Hosp Psych
Unexplained complaints in general practice: prevalence, patients’ expectations, and professionals’ test-ordering behavior
Med Decis Making
Medically unexplained symptoms in patients referred to a specialist rheumatology service: prevalence and associations
Rheumatology
Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study
Br Med J
Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity
Arch Gen Psychiatry
Resource utilization of patients with hypochondriacal health anxiety and somatization
Med Care
The use of hospitalizations by persistent somatizing patients
Psychol Med
A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms
Int J Psychiatry Med
Functional somatic syndromes
Ann Intern Med
Medically unexplained symptoms: exacerbating factors in the doctor–patient encounter
J R Soc Med
Chronic low back pain in general practice: the challenge of the consultation
Fam Pract
Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study
Fam Pract
Medically unexplained symptoms: perceptions of physicians in primary health care
Fam Pract
Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis
Br Med J
Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners
Br J Gen Pract
Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study
Br Med J
Physicians’ responses to patients’ medically unexplained symptoms
Psychosom Med
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
Psychosom Med
Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention
Psychosom Med
Short-term psychotherapeutic interventions for somatizing patients in the general hospital: a randomized controlled study
Psychother Psychosom
SOMS, screening for somatoform disorders—manual to the questionnaire (in German)
A user's guide to the general health questionnaire
Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners
Br J Gen Pract
Qualitative Sozialforschung: Lehrbuch
Cited by (49)
Exploring the acceptability of behavioral interventions for veterans with persistent “medically unexplained” physical symptoms
2023, Journal of Psychosomatic ResearchThe importance of contextual aspects in the care for patients with functional somatic symptoms
2020, Medical HypothesesLinguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review
2020, Journal of Psychosomatic ResearchCitation Excerpt :Patients experienced relatively severe complaints, and studies applied very diverse inclusion criteria since no gold standard exists for the operationalization of MUS (e.g. a minimum of four to six complaints [46], or follow-up consultations [41]). Though research has shown that certain practices in MUS consultations may be universal for different medical settings (i.e. neurology and psychotherapy) [66] or for different types of complaints [63], we found no evidence that specific practices described in individual studies account for all MUS interactions. Second, though studies in this review [28,44] and quantitative analyses [35,67] suggest that healthcare providers and patients sometimes use language differently depending on the type of complaints patients present, our review did not compare consultations involving patients with medically unexplained symptoms with consultations where the symptoms did have a medical explanation.
“Understand your illness and your needs”: Assessment-informed patient education for people with multiple functional somatic syndromes
2019, Patient Education and CounselingQuantifying positive communication: Doctor's language and patient anxiety in primary care consultations
2018, Patient Education and CounselingCitation Excerpt :Previous studies show that explanations of unexplained symptoms tend to be unclear, tentative and uncertain [25], with use of indirect formulations (e.g. “it is not an epileptic seizure”) [26] and vague labels (e.g. “counselling” instead of “psychotherapy”). Patients often react defensively towards psychosomatic explanations of symptoms [24,27]. The possibility exists that linguistic expressions used in these consultations contribute to these patients feeling stigmatised [28] and dissatisfied [29].