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. 2004 Mar;54(500):165–170.

Normalisation of unexplained symptoms by general practitioners: a functional typology.

Christopher F Dowrick 1, Adele Ring 1, Gerry M Humphris 1, Peter Salmon 1
PMCID: PMC1314825  PMID: 15006120

Abstract

BACKGROUND: Patients often present in primary care with physical symptoms that doctors cannot readily explain. The process of reassuring these patients is challenging, complex and poorly understood. AIM: To construct a typology of general practitioners' (GPs') normalising explanations, based on their effect on the process and outcome of consultations involving patients with medically unexplained symptoms. DESIGN OF STUDY: Qualitative analysis of audiotaped consultations between patients and GPs. SETTING: Seven general practices in Merseyside, United Kingdom. METHODS: Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively, to identify types of normalising speech used by GPs. RESULTS: Normalisation without explanation included rudimentary reassurance and the authority of a negative test result. Patients persisted in requesting explanation and elaborated or extended their symptoms, rendering somatic management more likely. Normalisation with ineffective explanation provided a tangible physical explanation for symptoms, unrelated to patient's expressed concerns. This was also counterproductive. Normalisation with effective explanation provided tangible mechanisms grounded in patients' concerns, often linking physical and psychological factors. These explanations were accepted by patients; those linking physical and psychological factors contributed to psychosocial management outcomes. CONCLUSIONS: The routine exercise of normalisation by GPs contains approaches that are ineffective and may exacerbate patients' presentation. However, it also contains types of explanation that may reduce the need for symptomatic investigation or treatment. These findings can inform the development of well-grounded educational interventions for GPs.

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Selected References

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  1. Barsky A. J., Borus J. F. Functional somatic syndromes. Ann Intern Med. 1999 Jun 1;130(11):910–921. doi: 10.7326/0003-4819-130-11-199906010-00016. [DOI] [PubMed] [Google Scholar]
  2. Barsky A. J., Ettner S. L., Horsky J., Bates D. W. Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care. 2001 Jul;39(7):705–715. doi: 10.1097/00005650-200107000-00007. [DOI] [PubMed] [Google Scholar]
  3. Baumann L. J., Cameron L. D., Zimmerman R. S., Leventhal H. Illness representations and matching labels with symptoms. Health Psychol. 1989;8(4):449–469. doi: 10.1037//0278-6133.8.4.449. [DOI] [PubMed] [Google Scholar]
  4. Escobar J. I., Gara M., Silver R. C., Waitzkin H., Holman A., Compton W. Somatisation disorder in primary care. Br J Psychiatry. 1998 Sep;173:262–266. doi: 10.1192/bjp.173.3.262. [DOI] [PubMed] [Google Scholar]
  5. Fitzpatrick R., Hopkins A. Referrals to neurologists for headaches not due to structural disease. J Neurol Neurosurg Psychiatry. 1981 Dec;44(12):1061–1067. doi: 10.1136/jnnp.44.12.1061. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Fitzpatrick R. Telling patients there is nothing wrong. BMJ. 1996 Aug 10;313(7053):311–312. doi: 10.1136/bmj.313.7053.311. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Kathol R. G. Reassurance therapy: what to say to symptomatic patients with benign or non-existent medical disease. Int J Psychiatry Med. 1997;27(2):173–180. doi: 10.2190/KBCC-PDRC-W93L-870J. [DOI] [PubMed] [Google Scholar]
  8. Kessel N. Reassurance. Lancet. 1979 May 26;1(8126):1128–1133. doi: 10.1016/s0140-6736(79)91804-x. [DOI] [PubMed] [Google Scholar]
  9. Lucock M. P., Morley S., White C., Peake M. D. Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey. BMJ. 1997 Sep 6;315(7108):572–575. doi: 10.1136/bmj.315.7108.572. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Mayou R. The nature of bodily symptoms. Br J Psychiatry. 1976 Jul;129:55–60. doi: 10.1192/bjp.129.1.55. [DOI] [PubMed] [Google Scholar]
  11. McDonald I. G., Daly J., Jelinek V. M., Panetta F., Gutman J. M. Opening Pandora's box: the unpredictability of reassurance by a normal test result. BMJ. 1996 Aug 10;313(7053):329–332. doi: 10.1136/bmj.313.7053.329. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Morriss R. K., Gask L., Ronalds C., Downes-Grainger E., Thompson H., Goldberg D. Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract. 1999 Apr;49(441):263–267. [PMC free article] [PubMed] [Google Scholar]
  13. Peters S., Stanley I., Rose M., Salmon P. Patients with medically unexplained symptoms: sources of patients' authority and implications for demands on medical care. Soc Sci Med. 1998 Feb-Mar;46(4-5):559–565. doi: 10.1016/s0277-9536(97)00200-1. [DOI] [PubMed] [Google Scholar]
  14. Peveler R., Kilkenny L., Kinmonth A. L. Medically unexplained physical symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res. 1997 Mar;42(3):245–252. doi: 10.1016/s0022-3999(96)00292-9. [DOI] [PubMed] [Google Scholar]
  15. Reid S., Whooley D., Crayford T., Hotopf M. Medically unexplained symptoms--GPs' attitudes towards their cause and management. Fam Pract. 2001 Oct;18(5):519–523. doi: 10.1093/fampra/18.5.519. [DOI] [PubMed] [Google Scholar]
  16. Salmon P., Peters S., Stanley I. Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. 1999 Feb 6;318(7180):372–376. doi: 10.1136/bmj.318.7180.372. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Salmon Peter, Dowrick Christopher F., Ring Adele, Humphris Gerry M. Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. Br J Gen Pract. 2004 Mar;54(500):171–176. [PMC free article] [PubMed] [Google Scholar]
  18. Schilte A. F., Portegijs P. J., Blankenstein A. H., van Der Horst H. E., Latour M. B., van Eijk J. T., Knottnerus J. A. Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. BMJ. 2001 Jul 14;323(7304):86–86. doi: 10.1136/bmj.323.7304.86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Speckens AEM, Spinhoven P., Van Hemert A. M., Bolk J. H. The Reassurance Questionnaire (RQ): psychometric properties of a self-report questionnaire to assess reassurability. Psychol Med. 2000 Jul;30(4):841–847. doi: 10.1017/s0033291799002378. [DOI] [PubMed] [Google Scholar]
  20. Stanley Ian M., Peters Sarah, Salmon Peter. A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms. Int J Psychiatry Med. 2002;32(2):125–140. doi: 10.2190/AVM3-8GU8-JW70-5RX5. [DOI] [PubMed] [Google Scholar]
  21. Walker E. A., Unützer J., Katon W. J. Understanding and caring for the distressed patient with multiple medically unexplained symptoms. J Am Board Fam Pract. 1998 Sep-Oct;11(5):347–356. doi: 10.3122/15572625-11-5-347. [DOI] [PubMed] [Google Scholar]
  22. Warwick H. M., Salkovskis P. M. Reassurance. Br Med J (Clin Res Ed) 1985 Apr 6;290(6474):1028–1028. doi: 10.1136/bmj.290.6474.1028. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Zaballa P., Crega Y., Grandes G., Peralta C. The Othmer and DeSouza test for screening of somatisation disorder: is it useful in general practice? Br J Gen Pract. 2001 Mar;51(464):182–186. [PMC free article] [PubMed] [Google Scholar]

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