Treating Medically Unexplained Symptoms

When patients are unconvinced by reassurance from their doctor that they have nothing to worry about, it may be because their emotional state makes it hard for them to remember all the information the doctor has given them, according to new research in PLoS Medicine.

Many people have worries about their health and seek a doctor's opinion when they have minor symptoms that concern them, for example headaches and stomach aches. If the doctor examines them and says that there is nothing to worry about, most people are reassured. However, some people have a long history of worrying about minor symptoms; they keep going back to the doctor because reassurance has failed. They are said to have "somatization syndrome". It is a common (and so far untreatable) condition that adds to the workload of medical staff and thus increases the cost of health care. Researchers in Germany conducted a study in which patients considered to have this condition were asked to listen to three audiotapes. For comparison, the same tapes were also played to healthy people and to patients with depression.

In one tape, a doctor gave test results to a patient with abdominal pain (a medical situation). The other two tapes dealt with a social situation (the lack of an invitation to a barbecue) and a neutral situation (a car breakdown). Each tape contained ten messages, including four that addressed possible explanations for the problem. Two were unambiguous and negative--for example, ''the reason for your complaints is definitely not stomach flu.'' Two were ambiguous but highly unlikely--''we don't think that you have bowel cancer; this is very unlikely.''

The researchers then assessed how well the participants remembered the likelihood that any given explanation was responsible for the patient's symptoms, the missing invitation, or the broken-down car. The patients with somatization syndrome overestimated the likelihood of medical causes for symptoms, particularly (and somewhat surprisingly) when the doctor's assessment had been unambiguous. By contrast, the other participants correctly remembered the doctor's estimates as low. The three study groups were similar in their recall of the likelihood estimates from the social or neutral situation. Finally, when asked to imagine that the medical situation was personally applicable, the patients with unexplained symptoms reacted more emotionally than the other study participants by reporting more concerns with their health.

These results suggest that people with somatization syndrome remember the chance that a given symptom has a specific medical cause incorrectly. This is not because of a general memory deficit or an inability to commit health-related facts to memory. The results also indicate that these patients react emotionally to medical situations, so they may find it hard to cope when a doctor fails to explain all their symptoms. Some of these characteristics could, of course, reflect the patients' previous experiences with medical professionals, and the study will need to be repeated with additional taped situations and more patients before firm recommendations can be made to help people with somatization syndrome.

Nevertheless, given that medical reassurance and the presentation of negative results led to overestimates of the likelihood of medical explanations for symptoms in patients with somatization syndrome, the researchers recommend that doctors bear this bias in mind. To reduce it, they suggest, doctors could ask patients for summaries about what they have been told. This would make it possible to detect when patients have misremembered the likelihood of various medical explanations, and provide an opportunity to correct the situation. This would benefit patients and reduce the strain on the health care system.

Citation: Rief W, Heitmüller AM, Reisberg K, Rüddel H (2006) Why reassurance fails in patients with unexplained symptoms--An experimental investigation of remembered probabilities. PLoS Med 3(8): e269. (http://dx.doi.org/10.1371/journal.pmed.0030269)