Original article
Patients with medically unexplained symptoms and their significant others: Illness attributions and behaviors as predictors of patient functioning over time

https://doi.org/10.1016/j.jpsychores.2009.09.012Get rights and content

Abstract

Objective

Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpersonal context. The current study examined MUS concurrently and prospectively by measuring specific interpersonal predictors of symptom severity and health care use.

Methods

A total of 127 patients with MUS and their significant others were recruited through primary care offices and assessed with self-report questionnaires and structured interviews about illness attributions, illness behavior and responses, relationship quality, symptom severity, and health care use at baseline and 6-month follow-up.

Results

Illness attributions and interpersonal illness behaviors of patients with MUS were cross-sectionally associated with illness attributions and responses of the patients' significant others. Relationship quality was related to specific illness behaviors and responses. Symptom severity at baseline was predicted by patients' somatic illness attributions. Symptom severity at 6-month follow-up was predicted by somatic illness attributions of patients and withdrawal of patients' significant others at baseline, but these predictors became insignificant when correcting for baseline symptomatology. Health care use at baseline was predicted by a greater amount of coping behavior and higher anxiety scores of patients, and health care use at 6-month follow-up was predicted by more attention-seeking behaviors and health care use of patients at baseline.

Conclusion

The results document the interpersonal influences on the maintenance of MUS. The perspective of significant others should be considered for enhancement of psychological approaches to the treatment of patients with MUS.

Introduction

Medically unexplained symptoms (MUS), that is, multiple physical symptoms that are not fully explained by a biomedical disease, are widespread. They are considered a burden to patients and their significant others and are assumed to be maintained in an interpersonal context. The present study was aimed at investigating—within the significant relationships of patients with MUS—specific cognitive and behavioral aspects associated with the patient's long-term functioning.

MUS are associated with interpersonal problems [1], [2], including more conflict and less cohesion within families [3]. Likewise, increased rates of personality disorders in patients with MUS (e.g., avoidant, schizotypal, paranoid, obsessive-compulsive, and histrionic personality disorders) [4], [5], [6] and evidence about insecure attachment styles [1], [7], [8] suggest interpersonal problems of these patients, including those with their significant others. However, specific cognitive and behavioral characteristics of patients' interactions with significant others and the impact of these characteristics on relationship quality, as well as on symptom severity and health care use, remain largely unclear [9], [10].

One cognitive variable that has proven to be clinically relevant for MUS but has scarcely been considered in an interpersonal context are illness attributions. According to current conceptualizations of somatoform disorders, patients with MUS utilize somatic illness attributions for their common somatic complaints [11], [12]. Indeed, one of the few investigations to examine illness attributions in an interpersonal context showed that patients with chronic fatigue syndrome, a medical syndrome frequently co-occurring with MUS, were most likely to endorse somatic attributions for their symptoms, as did their relatives for the patients' symptoms, although patients' relatives considered other explanations for their own complaints [13]. Furthermore, the type of illness attribution seems to be differentially relevant for symptomatology and treatment outcome: In patients with MUS, somatic illness attributions were cross-sectionally associated with more behavioral symptoms, for example, frequent verification of diagnosis or expression of symptoms, with more somatoform symptoms, and thereby with increased health care use [14], [15]. In contrast, psychological illness attributions were associated with comorbid depression and anxiety [15], [16]. Longitudinally, one clinical study of MUS showed that a decrease of somatoform symptoms, but not of health care use, was predicted directly by less somatic attributions, and indirectly through more anxiety and psychological attributions [17]. In chronic pain, a medical condition frequently characterized by MUS, there is emerging evidence to suggest that greater congruence between chronic pain patients and their spouses on pain-related variables is associated with patients' higher pain severity and less punishing spousal responses [18]. In light of these findings, the associations between illness attributions of patients with MUS and their significant others and the associations of illness attributions with interpersonal illness behavior and responses warrant further investigation in order to clarify the concurrent and longitudinal impact on symptom severity and health care use.

Among the behavioral aspects likely contributing to the maintenance of MUS, interpersonal responses of significant others such as solicitous, distracting, and punishing spousal responses were significantly associated with greater pain severity in chronic pain patients [9]. These illness responses were interpreted in terms of operant conditions [19]: while punishing spousal responses were associated with patients' decreased pain behavior, solicitous spousal responses were positively related to this behavior [20], [21], [22], [23]. Illness behavior and responses were further found to be associated with the perceived relationship quality in chronic pain couples [24], [25], [26]. Overall, because of the cross-sectional nature of this research, conclusions about longer-term implications of illness behavior and responses on symptom severity cannot be drawn. In MUS, illness behavior and responses, and relationship quality require further investigation, especially with regard to the long-term impact on patients' symptom severity and health care use.

In this context, it was hypothesized: (1) that patients' illness attributions and behaviors are significantly related with the illness attributions and responses of their significant others; (2) that illness behavior of patients and significant others' illness responses are associated with somatic illness attributions and relationship quality; (3) that somatic illness attributions and illness behavior and responses are cross-sectionally; and (4) longitudinally predictive of greater symptom severity and health care use. Depressiveness and anxiety were considered as control variables in the regression analyses because of their associations with psychological illness attributions.

Section snippets

Sample

Patients with MUS were recruited through 26 primary care offices at regular visits for a larger study involving a general practitioners (GP) training. This randomized GP training study used a waiting-list control group design and a 6-month follow-up period [27]. The main inclusion criterion was a history of multiple unexplained physical symptoms (at least two symptoms) that were not entirely explained by an established biomedical etiology [28]. Patients were excluded if biomedical reasons for

Hypothesis 1: PT illness attributions and behaviors are associated with SO illness attributions and responses

As presented in Table 2, PT and SO somatic illness attributions were significantly related, as were PT and SO psychological illness attributions (P<.01; large or medium effect size). Paired t tests revealed more PT than SO somatic and psychological illness attributions [somatic: 1.46±0.84 vs. 0.81±0.60, t(124)=8.88, P<.001; psychological: 2.18±1.00 vs. 1.94±1.14, t(124)=2.67, P=.009). Further, PT and SO coping, attention-providing/-seeking, and withdrawal showed significant positive

Discussion

Previous research suggested that MUS are maintained in an interpersonal context. The current study sought to specify, within significant relationships of patients with MUS, the cognitive and behavioral aspects that are predictive of concurrent and longer-term maintenance of patients' symptom severity and health care use.

According to our expectations, symptom severity was cross-sectionally predicted by interpersonally relevant variables, specifically somatic illness attributions of patients.

Acknowledgments

This study was supported by the German Ministry of Education and Research (BMBF) with grants 01GI9926 and 01GP0491 awarded to Winfried Rief.

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