The British Journal of Psychiatry (2008) 192: 314-315. doi: 10.1192/bjp.192.4.314a
© 2008 The Royal College of Psychiatrists
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Correspondence

Reattribution for medically unexplained symptoms

Hiske J. van Ravesteijn

Department of General Practice, Radboud University Nijmegen Medical Centre, The Netherlands. Email: h.vanravesteijn{at}hag.umcn.nl

Peter LBJ Lucassen

Department of General Practice, Radboud University Nijmegen Medical Centre

Tim C. olde Hartman

Department of Family Medicine, Radboud University Nijmegen, The Netherlands

Edited by Kiriakos Xenitidis and Colin Campbell

Morriss et al1 performed a high-quality cluster randomised controlled trial in which reattribution for medically unexplained symptoms was taught to general practitioners (GPs). We compliment the authors on this trial. Strong points of their trial are the avoidance of selection bias by using an independent GP for inclusion, and the inclusion of patients for whom unexplained symptoms of sufficient duration were the reason for the encounter. However, we have some critical comments as well.

First, the training of GPs took only 6 hours and was performed by non-expert trainers. Reattribution is not an easy technique to learn. Other researchers have used training programmes of at least 20 hours.2,3 The trainers in this study were three nurses and a psychologist. Although they were prepared intensively, they might not have been familiar enough with GP consultations. Consequently, we have doubts about the thoroughness and effectiveness of the training for GPs.

Second, the effect of reattribution training on doctor–patient communication has been evaluated in only one consultation. Reattribution usually takes more than one consultation.4 Making an inventory of the problems and broadening the agenda can lead to quite a disturbance of the normal flow of the consultation. Patients often need more time to make a link between their psychosocial and physical problems. In the article it seems like it was mostly the doctor who made the link. This does not fit into the original reattribution model. A negotiating style is needed in order to let the patient raise the possibility of a link him- or herself.4 For the purpose of effective reattribution, the patient has to come up with the link and not the doctor.2,3

Third, we know that the effectiveness of psychological treatments consists of specific and non-specific effects. Non-specific effects are effects caused by mutual trust, empathy and shared understanding.5 The training in reattribution and applying it might have influenced the physicians' relation with the patient negatively because of the physicians being absorbed by the application of the new intervention. Less attention for empathy and other non-specific effects might have been an additional cause for the absence of treatment effects.

Finally, it is a pity that the authors did not differentiate the outcome effects for subgroups. Patients with medically unexplained symptoms form a heterogeneous group. `Treatment effects are always moderate' due to the differences in levels of emotional and physical stress.6 The subgroup of patients with low emotional stress before treatment might have experienced deterioration in outcome measures after reattribution because of the consequent opening up and admittance of their problems. Although this is a clinically valuable change process, by reporting the overall treatment effects, this profit might be concealed.

In short, we think that some of the questions surrounding the treatment of patients with medically unexplained symptoms has been clarified by this high-quality trial, but there remain many others.

REFERENCES

    1
  1. Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, Lewis B, Charles-Jones H, Hogg J, Clifford R, Rigby C, Gask L. Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. Br J Psychiatry 2007; 191: 536 -42.[Abstract/Free Full Text]
    2. 2
  2. Blankenstein AH. Somatising patients in general practice. Reattribution, a promising approach. PhD thesis. University Medical Center, Vrije Universiteit, 2001.
    3. 3
  3. Rosendal, M. A randomized controlled trial of brief training in the assessment and treatment of somatization in primary care: effects on patient outcome. Gen Hosp Psychiatry 2007; 29: 364-73.[CrossRef][Medline]
    4. 4
  4. Goldberg D, Gask L, O'Dowd T. The treatment of somatisation: teaching techniques of reattribution. J Psychosom Res 1989; 33: 689 -95.[CrossRef][Medline]
    5. 5
  5. Stewart MA. Effective physician–patient communication and health outcomes: a review. Can Med Assoc J 1995; 152: 1423 -33.[Abstract]
    6. 6
  6. Schweickhart A, Larisch A, Fritzsche K. Differentiation of somatizing patients in primary care: why the effects of treatment are always moderate. J Nerv Ment Dis 2005; 193: 813-9.[CrossRef][Medline]



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T. olde Hartman, L. Hassink-Franke, C Dowrick, S Fortes, C Lam, H. van der Horst, P. Lucassen, and E. van Weel-Baumgarten
Medically unexplained symptoms in family medicine: defining a research agenda. Proceedings from WONCA 2007
Fam. Pract., August 1, 2008; 25(4): 266 - 271.
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