Reattribution reconsidered: Narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings
Section snippets
Background
Medically unexplained symptoms (MUS) refer to bodily symptoms that do not have a physical health explanation [1]. They are present in 3–19% of consultations with general practitioners [1], [2] and pose a major problem for health care systems in terms of their assessment, appropriate management and economic burden [3], [4]. In the context of MUS, the term reattribution was originally employed to denote the ascription of physical symptoms to a psychological cause. One of us (LG) co-authored a
Methods
We systematically searched the published literature with the specific objective of determining the impact that reattribution training and subsequent modifications of its original model have had on the process and outcome of care for people with medically unexplained symptoms.
Results
After removal of duplicates, 99 publications remained from which 20 were included in the review. A further 3 relevant research papers and 2 unpublished theses were added from searching of reference lists and the personal contacts/knowledge of the research team giving a total of 25 papers (Fig. 1).
These resulted from 13 different studies utilising the Reattribution model carried out in the United Kingdom (UK) [8], [9], [10], [11], [12], [22], [23], [24], [25], [26], [27], [30], [31], the
Qualitative findings
Research carried out in qualitative studies nested within trials has identified possible explanations for the mixed quantitative findings. For patients, Peters and colleagues [26] found that potential barriers to patient improvement include the perceived complexity of their problems and the difficulty experienced by patients in making judgements about how to manage their presentation of this complexity to the GP who they viewed as having a more simplistic understanding of the problem. Most
The impact of reattribution training
RT does not appear to offer a solution to the problem of managing medically unexplained symptoms in primary care in its current form. The basic skills can be acquired, but more extensive training, which would be unacceptable to most GPs in the UK (although the TERM model has now been widely disseminated in Denmark [18]), seems necessary to embed these skills and strategies. To be effective we suspect that GPs must be trained in an approach to the consultation in which they really explore
Conclusions
The reattribution model is too simplistic in its current form to address the needs of many people presenting with medically unexplained symptoms in primary care. In the broad terms of the original aims of the model set out at the beginning of this paper, we are still seeking to help patients to re-evaluate their beliefs and understanding of their problems, but we no longer consider it necessary to formally re-attribute symptoms to a psychological cause. The consultation process is best seen as
References (57)
- et al.
Medically unexplained symptoms in primary care; a comparison of self-report screening questionnaires and clinical opinion
J Psychosom Res
(1997) - et al.
The treatment of somatisation: teaching the skills of reattribution
J Psychosom Res
(1989) - et al.
The treatment of somatization: evaluation of a teaching package with general practice trainees
J Psychosom Res
(1989) - et al.
Treatment of patients with somatized mental disorder: effects of reattribution training on outcomes under the direct control of the family doctor
Psychosomatics
(2002) - et al.
Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners
Patient Educ Couns
(2002) - et al.
A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on patient outcome
Gen Hosp Psychiatry
(2007) - et al.
Assessment and treatment of functional disorders in general practice: the extended reattribution and management model — an advanced educational program for nonpsychiatric doctors
Psychosomatics
(2002) - et al.
Psychosocial interventions for somatizing patients by the general practitioner: a randomized controlled trial
J Psychosom Res
(2004) - et al.
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)
Gen Hosp Psychiatry
(2006) - et al.
Problem-solving therapy in the treatment of unexplained symptoms in primary care: a preliminary study
J Psychosom Res
(1994)