Abstract
Background:
Illness beliefs are significant contributors to health outcomes. Beliefs about the cause of physical symptoms is considered particularly important among those with medically unexplained symptoms and illnesses (MUS); yet little is known about causal beliefs among those with the most severe MUS (i.e., Veterans). The goal of the current study was to examine Veterans’ causal attributions of their physical symptoms.
Methods:
91 combat Veterans with MUS were surveyed using a mixed-methods design about the cause of their physical symptoms, physical symptom severity, and PTSD symptoms. Causal attributions of physical symptoms were analyzed through thematic response analysis and grouped into categories. Chi-square analysis was used to assess the distribution of causal attribution types across Veterans with varying physical symptom severity and PTSD symptom severity.
Results:
Veterans with MUS reported an average of 7.9 physical symptoms, and attributed the cause of their symptoms to seven different categories (“Don’t Know,” “Stress/Mental Health,” “Deployment/Environment,” “Functional/Symptom,” “Medically Explained,” “Medically Unexplained Syndrome,” and ‘Lifestyle”). Exploratory chi square analysis revealed significant differences in causal attributions across physical symptom severity and severity of PTSD symptoms. Veterans with more severe PTSD and physical symptoms were more likely to attribute their MUS to stress/mental health or to a medically unexplained syndrome compared to those with low/no PTSD symptoms and physical symptom severity. Veterans with minimal PTSD and physical symptom severity were more likely to attribute the cause of their MUS to lifestyle choices (e.g., exercise/diet) compared to those with high PTSD and physical symptom severity.
Conclusions:
Veterans with MUS endorse multiple, varied causal attributions for their physical symptoms, suggesting more complex causal beliefs than typically assumed. This has important implications for patient-provider communication and development of concordance around MUS treatment.
Keywords: Veterans, Causal attributions, physical symptoms, functional symptoms, PTSD
Persistent medically unexplained symptoms and illnesses (MUS), also termed persistent physical symptoms (PPS), are physical symptoms without a clear biological cause, common to multiple chronic conditions (e.g., back pain and stomach pain). MUS poses a prevalent and significant problem with an estimated 25-50% of patients seen by primary care providers presenting with MUS [1–3]. MUS impairs quality of life [4], and patients with MUS have higher levels of anxiety, depression, and poorer health-related outcomes than patients with better understood health conditions [4–7]. MUS is particularly relevant to Veterans with 23% to 37% of combat Veterans reporting at least one MUS [8,9] and having a higher prevalence of comorbid mental health (e.g., PTSD) problems than civilians [8–10].
According to the Common-Sense Model of Self-Regulation (CSM), beliefs about the cause of MUS symptoms are theorized to be a key conceptual pathway to health outcomes among patients and Veterans with MUS [11–13]. Specifically, the Common-Sense Model predicts that beliefs about what is causing one’s illness will direct the behavioral response to those symptoms, which in turn leads to either positive or negative health outcomes [14–16]. Patients’ attribution of MUS to a physical cause is thought to increase distress and attention to physical symptoms, resulting in increases in the intensity and chronicity of symptoms and greater healthcare utilization [17]. Empirical research has supported these Common-Sense Model tenets finding a relationship between causal attributions and health outcomes such as treatment adherence and quality of life among those with MUS [11–12,18]. In particular, attribution to a physical cause leads to a higher likelihood of experiencing physical symptoms.
It is widely believed that patients with MUS, particularly those with severe MUS, attribute their symptoms to a physical cause. Studies have demonstrated that patients with MUS are more likely to have a physical attribution for their symptoms as compared to patients without MUS [19]. Veterans are considered to be particularly likely to use physical explanations for their MUS as opposed to psychological or social explanations due to military culture where psychological explanations can be viewed as a sign of weakness [20]. Similarly, qualitative interviews with providers reveal that providers believe patients with MUS focus on physical attributions, pressuring them for medical interventions – despite feeling that their role as a provider is to offer reassurance to patients [21–22].
Given the relationship between illness beliefs and health outcomes, current behavioral interventions to treat MUS focus on changing the patient’s symptom attributions [23]. Reattribution treatment, for example, trains general practitioners to help patients reframe attributions about MUS from a physical to a psychological cause [24]. Cognitive behavioral therapy, similarly, teaches patients the link between thoughts, behaviors, and physical symptoms. While these treatments are helpful for some patients, their efficacy is lower for treating MUS than treatments for other disorders (e.g. anxiety/depression) [25]. One reason may be that our understanding of MUS patients’ causal explanations is less clear than expected.
Recent studies have found that patients’ attributions of MUS are more complex than originally believed [26–27]. A quantitative study of pain attributions found that patients with chronic pain gave 3.86 attributions per symptom [28]. A qualitative study found that patients endorsed multiple attributions for their symptoms but were selective about which attribution they used in a specific context. For example, patients might talk about physical attributions in the physician office and psychological attributions with a psychologist [29]. There is also evidence that patients with MUS do not pressure providers for medical interventions; rather providers are more likely to suggest medical interventions despite patients being open to alternative interventions [30]. Patient-level factors further complicate patients’ attributions. For example, less severe physical symptoms and better physical functioning are associated with psychosocial illness attributions (e.g., stress) as opposed to physical attributions [31]. Similarly, patients with comorbid mental health conditions, which are a common comorbidity among patients with MUS [11,32], tend to attribute their MUS to both physical causes and mental/psychosocial causes [11,32]. Previous research examining Veterans with MUS and mental health concerns (e.g., PTSD), which are also a common comorbidity among patients with MUS [33], found that mental health concerns affect how Veterans think about their health [31]. Thus, not only symptom severity, but also PTSD symptoms, are important patient-level factors to consider among Veterans with MUS.
Together, this body of work suggests that symptom attributions are complex; however, there are also limitations in extant research. Research has primarily asked patients to respond to a set list of causes, which may miss common attributions endorsed by patients. Further, research has typically asked about MUS as one condition (e.g., chronic pain or IBS), yet patients may have different attributions (e.g., physical or psychological) for different symptoms (e.g., low back pain and gastrointestinal symptoms).
Improving our understanding of patients’ attributions for their MUS is important to improve treatment outcomes. In addition to the previously cited research linking causal beliefs to treatment adherence, quality of life, and symptom severity [11–12,18], research suggests that the key to improving care of patients with MUS is to have patients and providers develop concordant beliefs about MUS [34–35]. For example, Burton [3] and colleagues have suggested that functional explanations may be particularly helpful in building concordant beliefs between patients and providers. Functional explanations provide a mechanistic understanding of symptoms (e.g., overactive nerves). Improving our understanding of patients’ attributions of their symptoms is a necessary first step to clarify how patients and physicians can develop concordant beliefs surrounding MUS. This is particularly important for the Veteran population, where one third report dissatisfaction with their healthcare and poor provider communication [36].
Therefore, causal illness beliefs among combat Veterans with MUS were examined. In the current study, Veterans seeking treatment at a tertiary clinic with expertise in medically unexplained symptoms were asked if they have any of 15 physical symptoms and if so, the cause of the symptoms. Our aim was to determine Veterans with MUS common causal attributions for their physical symptoms and understand if attributions differ depending on level of physical symptom severity and post-traumatic stress disorder (PTSD) symptoms. The hypothesis for the current study is that Veterans would have multiple and diverse attributions for their symptoms, and greater PTSD symptoms would be associated with higher prevalence of mental health attributions. Focusing on a Veteran population will help us understand the diversity of causal attributions among a population thought to be particularly focused on physical explanations for their MUS. Understanding attributions may better inform more tailored and efficacious treatment of MUS.
Methods
Participants and Procedure
The current study was reviewed by the Institutional Review Board (IRB) at the Veterans’ Affairs. Participants were provided informed consent and considered to be at minimal risk per the IRB. Postal mail surveys were sent to ~1000 Veterans who had been referred for care to the tertiary clinics. There were 91 responses, which is a 9% response rate; however, it is estimated that due to inaccurate postal addresses, up to 50% of potential participants may not have received the survey. Veterans were also asked questions about their PTSD symptoms.
Measures
Physical Symptoms.
The Patient Health Questionnaire – 15 (PHQ-15) asks participants to rate how much they have been bothered by 15 symptoms during the past four weeks. Participants were asked to rate how bothered they were using a 3-point scale (0=Not bothered at all to 2=Bothered a lot). Sample items included “stomach pain,” “pain in your arms, legs, or joints (knees, hips, etc.)”, and “chest pain”. The severity of participants’ physical symptoms were categorized as minimal/low, moderate, or high based on previously established and validated cutoff scores of 5, 10, and 15 respectively [37]. The PHQ-15 has been shown to be reliable and valid in numerous samples and settings [38].
Attribution of Symptoms.
After completing the PHQ-15, participants were asked what they “thought caused the physical symptoms.” Participants could provide any length answer they wanted, and therefore could provide multiple attributions. Responses were later coded into categories.
PTSD.
PTSD symptoms were assessed with the PTSD Checklist for DSM-IV, military version (PCL-M) [39]. The PCL-M is a 17-item measure that asks participants to rate how much they have been bothered by each PTSD symptom over the last month using a 4-point scale (1=not at all to 5=extremely). Sample items include: “Repeated, disturbing memories, thoughts, or images of a stressful military experience?” and “Avoid activities or talking about a stressful military experience or avoid having feelings related to it?” The severity of participants’ PTSD symptoms were categorized as no/low, sub-clinical, or clinical based on cutoff scores of 17-24, 25-50, or above 50 respectively [40]. Good reliability and validity of scores on this measure have been shown [41–43].
Data Analysis
Attribution Domains.
The coding of the attributions was completed in two steps. All potential codes were based on all responses provided by Veterans. In the first step, LMM created a list of potential codes based on the responses. NA reviewed the codes and the responses and suggested additions or subtractions to the codes. Once the codes were established LMM and NA each individually coded the entire sample. Responses were compared, and discrepancies were resolved. After discussion, LMM and NA agreed upon 100% of the codes, resulting in seven domains (see below). Discrepancies were discussed among coders until 100% agreement was reached. If one participant listed two causes for a single symptom that fell within the same category, these were counted once (e.g., if a participant stated their stomach pain was caused by depression and anxiety – this was coded once as mental health).
Chi-Square.
To address how physical symptom severity and PTSD symptoms affect the distribution of Veterans’ causal attributions, a chi-square test was used.
Results
Descriptive Statistics
On average, Veterans reported 0.97 attributions per physical symptom (M=7.98; SD=3.69) endorsed. The prevalence of physical symptom severity was high (37.3%), moderate (23.1%), and minimal/low (39.6%). The mean of physical symptom severity was 12.26 (SD=6.77). Of the 91 Veterans who participated in the study, 29.2% (n=26) did not meet threshold for PTSD (no symptoms/minimal symptoms), 30.3% (n=27) met subclinical threshold for PTSD, and 40.4% (n=36) met clinical threshold for PTSD. The mean of PTSD symptoms was 49.9 (SD=20.19).
Causal Attributions
Across the 91 Veterans, there were a total of 705 attributions for any of the symptoms with the following categories, and frequencies, of causal attributions for physical symptoms:
Do not Know (endorsed 129 times or 18.3% of all attributions): Examples included: “I don’t know what’s causing the symptoms” “Don’t know why-never seem to have enough energy anymore.”
Stress/Mental Health (endorsed 170 times or 24.1% of all attributions): Examples included: “suppressed feelings and stress” “stress, overeating” “anxiety and nervousness” “sometimes I just get overwhelmed with work and school, nothing good comes easy so I just have to keep moving.”
Deployment/Environmental (endorsed 88 times 12.5% of all attributions): Examples included: “Sandstorm exposure” “Extreme heat or cold during deployment” “service connected nerves frequent vomiting and wretching” “had pain in lower back since returning home from deployment possibly from body armour worn on duty” “started when I was in middle east” “unresolved issue from two deployments.”
Functional Symptoms (endorsed 92 times or 13.0% of all attributions): Examples included: “bad knees” “old sprain” “bad equilibrium” “my colon hates me” “disk bulges in lumbar spine.”
Medically Explained and Iatrogenic (endorsed 134 times or 19.0% of all attributions): Examples included: “acid reflux” “asthma” “bronchitis” “medication (omeprazole) helps to control symptoms.”
Medically Unexplained Syndrome (endorsed 17 times or 2.4% of all attributions): Examples included: “irritable bowel syndrome” “fibromyalgia.”
Lifestyle (endorsed 75 times or 10.6% of all attributions): Examples included: “a little out of shape” “I smoke” “overweight” “shiftwork”
The percentage of each causal attribution by physical symptom is reported in Table 1. Notable findings include more frequent attributions to stress/mental health for autonomic symptoms such as heart racing (66.7%) and trouble sleeping (41.6%), and more frequent attributions to deployment and medically explained causes for back pain (30.9% and 36.8% respectively) and arm/leg pain (27.4% and 32.9% respectively). Few attributions were for medically unexplained syndrome as the cause of their symptoms. Stomach pain had the highest percentage of the attributions being due to a medically unexplained syndrome (10.0%) followed by constipation/diarrhea (6.1%) and nausea/gas/indigestion (6.0%).
Table 1.
Causal Attributions of Physical Symptoms*
| Physical Symptom | Don’t know | Stress/Mental Health | Deployment/Environment | Functional Symptom | Medically Explained | Medically Unexplained Syndrome | Lifestyle |
|---|---|---|---|---|---|---|---|
| Stomach pain (n=43; # of attributions=40) | 10.0% | 15.0% | 7.5% | 30.0% | 20.0% | 10.0% | 7.5% |
| Back pain (n=66; # of attributions=68) | 7.3% | 5.9% | 30.9% | 11.8% | 36.8% | 2.9% | 4.4% |
| Arm/Leg Pain (n=77; # of attributions=73) | 11.0% | 1.3% | 27.4% | 17.8% | 32.9% | 4.1% | 5.5% |
| Menstrual Cramps (n=7; # of attributions=6) | 33.3% | - | 16.7% | 16.7% | 33.3% | - | - |
| Sex Pain (n=40; # of attributions=36) | 22.2% | 22.2% | - | 36.1% | 16.7% | - | 2.8% |
| Headaches (n=56; # of attributions=63) | 19.0% | 25.4% | 8.0% | 11.1% | 28.6% | 1.6% | 6.3% |
| Chest Pain (n=39; # of attributions=28) | 32.1% | 39.3% | 3.6% | 3.6% | 10.7% | - | 10.7% |
| Dizziness (n=37; # of attributions=35) | 37.1% | 11.5% | 11.4% | 14.3% | 25.7% | - | - |
| Fainting Spells (n=9; # of attributions=11) | 45.5% | 18.1% | 18.2% | 9.1% | - | - | 9.1% |
| Feeling Heart Pound or Race (n=46; # of attributions=39) | 15.4% | 66.7% | 5.1% | 5.1% | 2.6% | - | 5.1% |
| Shortness of Breath (n=46; # of attributions=46) | 13.0% | 26.1% | 17.4% | 6.5% | 19.6% | - | 17.4% |
| Constipation/Diarrhea (n=43; # of attributions=49) | 26.5% | 16.4% | 6.1% | 12.2% | 24.5% | 6.1% | 8.2% |
| Nausea/Gas/Indigestion (n=58; # of attributions=50) | 26.0% | 16.0% | 4.0% | 10.0% | 18.0% | 6.0% | 20.0% |
| Tired (n=79; # of attributions=83) | 18.1% | 38.6% | 8.4% | 2.4% | 6.0% | 1.2% | 25.3% |
| Trouble Sleeping (n=80; # of attributions=78) | 13.0% | 41.6% | 10.4% | 16.9% | 3.9% | - | 14.3% |
| All Symptoms (n=91; # of attributions=705) | 18.3% | 24.1% | 12.5% | 13.0% | 19.1% | 2.4% | 10.6% |
There were 705 attributions across the 91 Veterans. For each symptom we report the number of Veterans who endorsed having the symptom (n=) and the number of attributions for the symptom across all Veterans (# of attributions=xx).
We then report the % of the attributions for each category. E.g., for stomach pain, 43 Veterans reported 40 different attributions, 10% of these attributions were “Don’t Know”, 15% of these attributions were “Stress/Mental Health”, 7.5% of these attributions were “Deployment/Environment”, 30.0% of these attributions were “Functional Symptom”, 20.0% of these attributions were “Medically Explained”, 10.0% of the attributions were “Medically Unexplained Syndrome”, and 7.5% of these attributions were “Lifestyle”.
Cross Tabulation
Chi-square analysis revealed significant differences for the distribution of causal attribution types across Veterans with varying physical symptom severity (no/low, moderate, high), χ(12)= 44.81, p < .001 (Table 2). There was a significant difference in causal attributions for physical symptoms between Veterans with higher physical symptom severity and Veterans with lower physical symptom severity. For example, a greater percentage of the attributions of Veterans with high and moderate physical symptom severity were for stress/mental health compared to the attributions of Veterans with no/low symptom severity (27.9%, 26.9%, and 10.5% respectively). Additionally, 4.1% of the attributions of Veterans with high physical symptom severity were for a medically unexplained syndrome compared to 0% of the attributions of Veterans with moderate and 0.7% of the attributions of Veterans with no/low physical symptom severity.
Table 2.
Symptom Attribution by Level of Physical Symptom *
| Level of Physical Symptom | Don’t know | Stress/Mental Health | Deployment/Environment | Functional Symptom | Medically Explained | Medically Unexplained Syndrome | Lifestyle |
|---|---|---|---|---|---|---|---|
| No/Low Physical Symptom (n=36, # of attributions =143) | 20.3% | 10.5% | 16.8% | 12.6% | 21.7% | 0.7% | 17.5% |
| Moderate Physical Symptoms (n=21, # of attributions =175) | 14.9% | 26.9% | 11.4% | 12.6% | 20.0% | 0.0% | 14.3% |
| High Physical Symptoms (n=34, # of attributions = 387) | 19.1% | 27.9% | 11.4% | 13.4% | 17.6% | 4.1% | 6.5% |
There were 705 attributions across the 91 Veterans. We report the number of Veterans representing each level of physical symptoms (n=) and the number of attributions at each level of physical symptoms (# of attributions=xx).
We then report the % of the attributions for each category. E.g., for “No/Low Physical Symptom” group, 36 Veterans reported 143 different attributions, 20.3% of these attributions were “Don’t Know”, 10.5% of these attributions were “Stress/Mental Health”, 16.8% of these attributions were “Deployment/Environment”, 12.6% of these attributions were “Functional Symptom”, 21.7% of these attributions were “Medically Explained”, 0.7% of the attributions were “Medically Unexplained Syndrome”, and 17.5% of these attributions were “Lifestyle”.
Conversely, 17.5% of the attributions of Veterans with no/low physical symptom severity were for lifestyle compared to only 6.5% of the attributions of Veterans with high physical symptoms. A larger percentage of the attributions of Veterans with no/low physical symptoms (16.8%) were for deployment/environment compared to Veterans with high and moderate physical symptoms (11.4% each).
Less notable findings (i.e., more equal proportion) emerged when we examined the distribution of attributions between no/low, moderate, and high physical symptom severity for the following causal attributions: unclear cause/don’t know, functional symptoms, and medically explained.
PTSD symptoms and causal attribution distribution
Chi-square analysis revealed significant differences for the distribution of causal attribution types across Veterans with different levels of PTSD symptoms (no/low, sub-clinical, clinical), χ(12) = 77.90 p < .001 (Table 3). There was a significant difference in causal attributions for physical symptoms between Veterans with clinical PTSD symptoms and Veterans with sub-clinical or no/low PTSD symptoms. For example, a greater percentage of the attributions of Veterans with clinical PTSD symptoms were stress/mental health compared to Veterans with no/low PTSD symptoms (32.2% vs. 4.8% respectively). Additionally, 4.6% of the attributions of Veterans with clinical PTSD symptoms were a medically unexplained syndrome compared to 0.8% of Veterans with sub-clinical and no/low PTSD symptoms.
Table 3.
Symptom Attribution by Level of PTSD*
| Level of PTSD Symptom | Don’t know | Stress/Mental Health | Deployment/Environment | Functional Symptom | Medically Explained | Medically Unexplained Syndrome | Lifestyle |
|---|---|---|---|---|---|---|---|
| No/Low PTSD Symptom (n=26, # of attributions =174) | 18.4% | 4.8% | 19.2% | 17.6% | 25.6% | 0.8% | 13.6% |
| Sub-Clinical PTSD Symptoms (n=27, # of attributions =312) | 23.8% | 22.4% | 15.2% | 10.8% | 13.0% | 0.0% | 14.8% |
| Clinical PTSD Symptoms (n=36, # of attributions = 213) | 15.1% | 32.2% | 8.5% | 12.5% | 20.2% | 4.6% | 6.8% |
There were 699 attributions across the 89 Veterans. We report the number of Veterans for each clinical threshold for PTSD symptoms (n=) and the number of attributions at each PTSD clinical threshold (# of attributions=xx).
We then report the % of the attributions for each category. E.g., for “No/Low Physical Symptom” group, 26 Veterans reported 174 different attributions, 18.4% of these attributions were “Don’t Know”, 4.8% of these attributions were “Stress/Mental Health”, 19.2% of these attributions were “Deployment/Environment”, 17.6% of these attributions were “Functional Symptom”, 25.6% of these attributions were “Medically Explained”, 0.8% of the attributions were “Medically Unexplained Syndrome”, and 13.6% of these attributions were “Lifestyle”.
Conversely, 13.6% of the attributions of Veterans with no/low PTSD symptoms were for lifestyle compared to only 6.8% of the attributions of Veterans with clinical PTSD symptoms. A larger percentage of the causal attributions of Veterans with no/low PTSD symptoms (19.2%) were for deployment/environment compared to Veterans with clinical PTSD symptoms (8.5%).
The presence of sub-clinical PTSD symptoms also affected the distribution of causal attributions with 23.8% of the attributions of Veterans with sub-clinical PTSD symptoms stating that they did not know the cause of their physical symptoms compared to only 15.1% of the attributions of Veterans with clinical PTSD symptoms. Similarly, only 13.0% of the attributions of Veterans with sub-clinical PTSD symptoms endorsed a medically explained attribution for their physical symptoms compared to 25.6% of the attributions of Veterans with no/low PTSD symptoms and 20.2% of the attributions of Veterans with clinical PTSD symptoms.
Less notable findings (i.e., more equal proportion) emerged when we examined the distribution between PTSD symptom severity for functional symptom attributions.
Discussion
The goal of the current study was to better understand Veterans’ causal attributions of their physical symptoms. The Common-Sense Model proposes that causal attributions about physical symptoms are key conceptual pathways to understanding health outcomes, especially among patients and Veterans with MUS. That is, how patients with MUS think about their health affects how the self-manage their physical symptoms and how they interact with their healthcare providers (e.g., patient-physician communication). Our results showed that, on average, Veterans with MUS reported 7.9 physical symptoms and had 0.97 attributions per symptom. They attributed the cause of their physical symptoms to the following seven categories: stress/mental health, deployment/environmental, medically explained/iatrogenic, medically unexplained syndromes, functional (e.g., an old injury), lifestyle (e.g., poor diet), and unknown causal factors. These findings suggest that Veterans with MUS commonly endorse multiple symptoms and view these symptoms through a multifactorial perspective. This is in contrast to previous research which has found non-Veteran patients with MUS are more likely to report a biological view, physical cause, for their symptoms [28]. Our findings highlight a more complex, biopsychosocial understanding of MUS among Veterans rather than a distinct biological or psychosocial attribution alone.
The distribution of causal attribution types varied by type of physical symptom. Veterans attributed autonomic symptoms (i.e., chest pain, heart pounding or racing, tiredness, and trouble sleeping) to stress and/or mental health; whereas, Veterans primarily attributed the cause of their musculoskeletal pain (i.e., back pain or arm/leg pain) to deployment or medically explainable causes. Interestingly, few Veterans attributed the cause of their symptoms to a medically unexplained syndrome, while large percentages endorsed not knowing the cause of their symptoms, particularly not knowing the cause of fainting spells and dizziness (45.5% and 37.1% respectively). These findings suggest that Veterans assign different causal attributions for different physical symptoms, as opposed to attributing symptoms to a single underlying factor. When working with Veterans with multiple chronic symptoms, it may be important to assess attributions at the symptom-level in order to fully understand the veteran’s viewpoint.
To better understand these causal attributions, causal attributions were tested to observe variations based on certain Veteran characteristics. Veterans with more severe physical symptom complaints and those with more severe PTSD symptoms were more likely to attribute their MUS to stress/mental health or to a medically unexplained syndrome. Conversely, Veterans with no/low physical symptom severity and minimal PTSD symptoms were more likely to attribute the cause of their physical health symptoms to lifestyle choices (e.g., exercise/diet). One possible explanation is that Veterans with more severe mental and physical health symptoms may have more experience with the health care system, and therefore may be better educated on the relationship between stress, mental health, and physical health compared to those with minimal symptoms [38–44]. Regardless, our findings highlight that person-level contextual factors (e.g., PTSD symptoms) influence the way in which MUS symptoms are interpreted and understood – providing further support that a biopsychosocial understanding might be useful to understand MUS symptoms.
Implications
These results have important implications for patient-provider communication. Research supports concordance (i.e., agreement between provider and patient on the cause of and treatment for MUS) as an important predictor of patient treatment outcomes such as treatment adherence and symptom improvement [45–46]. For example, Phillips, Leventhal, & Leventhal [47] found that when providers understood their patients’ presenting problems and treatment, patients reported significantly better treatment outcomes including improved adherence to treatment recommendations. Discordance, on the other hand, can have negative impacts on patient health, including negative emotions related to feeling misunderstood or invalidated by healthcare providers and the larger healthcare system [48–50]. Yet disagreement between physicians and patients about the cause and treatment of MUS is common [48,51]. Our findings suggest physicians should communicate with Veterans who have MUS through a multidimensional, biopsychosocial lens in order to better develop concordance around the diversity of causal attributions endorsed by this population. Our findings further highlight that physicians may want to be attuned to not only physical symptom severity, but PTSD symptom severity, as this may indicate a potential stress/mental health attribution of symptoms that will be important to consider in developing concordance around treatment options. Likewise, incorporation of a variety of interventions that target each causal attribution (e.g., biological, psychological, and lifestyle interventions) may also improve patient-physician concordance; however, future research is warranted to address this question.
Strengths & Limitations
The current study focused on Veterans with MUS seeking healthcare. Veterans are disproportionately burdened by MUS, and therefore improving our understanding of this population is important. Determining Veterans beliefs may also help us understand the beliefs of all patients with MUS. Veterans are thought to be particularly likely to have a physical attribution for their MUS. Our finding that those thought to be most likely to have a physical explanation for their MUS actually have a biopsychosocial explanation, suggests that populations with less severe MUS may also have a biopsychosocial model. However, it is also possible that the results will not generalize to other populations, including not generalizing to Veterans with MUS who are not seeking care. Certain factors unique to the Veteran population, such as greater number/severity of physical symptoms or cultural attitudes towards health and illness, may contribute to more varied causal attributions of physical health among Veterans. Another strength of the study was the use of open-ended questions which allowed us to assess patient-generated attributions.
While our findings provide information that may be helpful in developing patient-physician concordance specific to Veterans with MUS [35], the current study was cross-sectional; therefore, it is unknown how Veterans’ attributions change over time and how attribution shifts relate to treatment outcomes (i.e., symptom and/or quality of life). As a result, the current study is unable to address how patient characteristics, including age or gender, and changes in patient characteristics (i.e., PTSD symptoms) affect attribution variations over time. Such information, in addition to more robust statistical procedures (e.g., structural equation modeling), would expand our understanding of not only the relationship between causal attributions and health symptoms – but also patient-physician concordance. Additionally, the sample size and response rate were low, and therefore our sample might reflect a specific subset (e.g., a help-seeking subset) of Veterans. The current study also used DSM-IV PTSD criteria which might not capture the current DSM-5 criteria used within clinical practice. Further, future research examining the variation in attributions according to type of symptom versus symptom severity alone, can help further clarify Veterans’ causal attributions of their physical symptoms.
Conclusion
Our findings support that Veterans with MUS view their physical health symptoms through a multidimensional lens. Veterans with MUS attribute their physical symptoms to more than just physical causes and often attribute the cause of their physical symptoms to stress and mental health. According to the Common-Sense Model, understanding these causal attributions of MUS is important as they provide key conceptual pathways to understanding health outcomes. Thus, these data have implications for clinical practice that include developing patient-physician concordance around the cause of and treatment for MUS among a Veteran population.
Acknowledgments
This work was supported by Merit Review Award #I01CX001053 from the United States (U.S.) Department of Veterans Affairs Clinical Sciences Research and Development; and a Career Development Award #IK2HX001369 from VA Health Services Research and Development Program. It was also supported by the VA NJ War Related Illness and Injury Study Center. ClinicalTRials.gov Identifier: NCT02161133.
Footnotes
Ethical Statement: The current study was reviewed by the Institutional Review Board (IRB) at the Veterans’ Affairs. Participants were provided informed consent and considered to be at minimal risk per the IRB. Therefore, the current study upholds the standards of the Helsinki 1964 declaration.
“All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.”
Contributor Information
Justin Kimber, University at Albany, State University of New York
Nicole Sullivan, Veterans Affairs New Jersey Healthcare System
Nicole Anastasides, Veterans Affairs New Jersey Healthcare System
Sarah Slotkin, University at Albany, State University of New York.
Lisa M. McAndrew, Veterans Affairs New Jersey Healthcare System University at Albany, State University of New York.
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