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Clinician Attributions for Symptoms and Treatment of Gulf War–Related Health Concerns
Ralph D. Richardson, PhD;
Charles C. Engel, Jr, MD, MPH;
Miles McFall, PhD;
Katherine McKnight, PhD;
James K. Boehnlein, MD;
Stephen C. Hunt, MD
Arch Intern Med. 2001;161:1289-1294.
ABSTRACT
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Background Several clinical syndromes are defined solely on the basis of symptoms,
absent an identifiable medical etiology. When evaluating and treating individuals
with these syndromes, clinicians' beliefs might shape decisions regarding
referral, diagnostic testing, and treatment. To assess clinician beliefs about
the etiology and treatment of "Gulf War illness," we surveyed a sample of
general internal medicine clinicians (GIMCs) and mental health clinicians
(MHCs).
Methods Clinicians (77 GIMCs and 214 MHCs) at the Veterans Affairs Puget Sound
Health Care System, Seattle, Wash, and the Veterans Affairs Medical Center
in Portland, Ore, responded to a mailed survey of their beliefs about Gulf
War illness.
Results Compared with GIMCs, MHCs were more likely to believe that Gulf War
illness was the result of a "physical disorder" and that symptoms resulted
from viruses or bacteria, immunizations, exposure to toxins, chemical weapons,
or a combination of toxins and stress (P < .05).
Conversely, GIMCs were more likely than MHCs to believe that Gulf War illness
was a "mental disorder" and that symptoms were due to stress or posttraumatic
stress disorder (P < .05). In addition, MHCs were
more likely to endorse biological interventions to treat Gulf War illness
(P < .01), whereas GIMCs were more likely to endorse
psychological interventions.
Conclusions Clinicians' beliefs about the etiology and effective treatment of Gulf
War illness vary and thus might contribute to the multiple referrals often
reported by Gulf War veterans. Health care models for Gulf War veterans and
others with symptom-based disorders necessitate collaborative interdisciplinary
approaches.
INTRODUCTION
SEVERAL COMMONLY encountered clinical disorders are defined solely by
their constellation of physical symptoms, in the absence of an identifiable
medical etiology. Among these disorders are fibromyalgia, chronic fatigue
syndrome, chemical sensitivity syndrome, irritable bowel syndrome, somatization
disorder, and "Gulf War illness." Exigencies of day-to-day clinical practice
often require clinicians to explain the causes of these disorders to patients
and to embark on a course of treatment. This task is often challenging, given
the dearth of knowledge about the pathogenesis of these disorders and the
lack of evidence-based treatment guidelines. Under these circumstances, the
unique experiences and perspectives of clinicians might shape beliefs about
the course of these often vague clinical syndromes and decisions about treatment.
A growing body of evidence suggests that clinicians' attitudes, beliefs,
and biases affect their decisions regarding treatment of clinical disorders.
Physicians report that they provide more education, encourage more contact,
and prescribe more medication to patients they perceive as likable and competent
than to those they regard as less competent and less likable.1
Clinicians' beliefs about pathogenesis also strongly affect the type and amount
of treatment a patient receives. For example, in a group of patients complaining
of fatigue, general practitioners were less likely to perform physical examinations,
diagnostic tests, and medical treatment if the fatigue symptoms were believed
to be "psychosocially attributed" rather than "somatically attributed."2 Among patients experiencing myocardial infarction,
nurses' causal attributions have been demonstrated to affect the interventions
they prescribe. Ogden and Knight3 found that
if the nurse believed that a patient's cardiac event was due to an "unhealthy
lifestyle" he or she was more likely to view the patient as noncompliant with
advice and as responsible for the event. Several studies4-5
have found that mental health providers' perceptions of the controllability
of the presenting problem and judgments regarding level of patient responsibility
affect the type of interventions these clinicians apply. Similarly, Brewin6 found that medical students were more willing to prescribe
psychotropic drugs for patients they believed had symptoms related to events
that were uncontrollable as opposed to controllable.
In addition, physicians describe certain patients who seek primary care
for vague or unexplainable symptoms as frustrating or "difficult."7-8 It also has been noted that when clinicians
and patients have contrasting views of the patient's illness, the patient
is perceived as more frustrating by the clinician.9
The medical care of difficult patients has been found to involve more chronic
problems, more medications, more radiographic and laboratory tests, more referrals,
and more medical visits.10 On average, these
patients report lower satisfaction with their care and are more likely to
leave the care of one clinician in search of another.11
Gulf War veterans often report a variety of vague physical symptoms
of unclear medical etiology.12 Some investigators13-14 have estimated that 15% to 20% of
Gulf War veterans seeking care for their war-related health concerns endorse
chronic and poorly understood physical symptoms, including fatigue, joint
and muscle pain, headaches, and cognitive problems. To date, no unique disease,
toxic exposure, or pathophysiologic mechanism has been established to explain
these symptoms, and no definitive treatment has emerged.
The illnesses of Gulf War veterans present a unique opportunity to investigate
clinicians' attributions about cause, clinical course, and treatment because
of the popular wisdom that these illnesses might represent a singular "syndrome."
In the extensive clinical experience of some investigators15-16
caring for Gulf War veterans with multiple idiopathic physical symptoms, many
veterans report that they see multiple clinicians without receiving an explanation
for their symptoms. Often these veterans complain that clinicians refer them
for repeated diagnostic tests without explanation or a clearly stated rationale.
This "medical merry-go-round" is often characterized by a general medical
provider referring the Gulf War veteran to a mental health provider and vice
versa. This type of referral process can leave the patient feeling frustrated
or abandoned and clinicians from all specialties feeling helpless and sometimes
unwilling or unable to offer useful interventions or the appropriate individualized
attention required for effective treatment. We also believed that the medical
merry-go-round experienced by some Gulf War veterans might be exacerbated
by clinicians' views of the pathogenesis of Gulf War illness. Indeed, as much
as any medical challenge in recent memory, Gulf War illness has highlighted
the limitations of our prevailing biomedical approach to illness.
The purpose of this study was to survey general internal medicine clinicians
(GIMCs) and mental health clinicians (MHCs) to identify and contrast their
beliefs about the causal attributions, clinical course, and treatment of medically
unexplained physical symptoms in Gulf War veterans. Based on anecdotal reports
by Gulf War patients and the lack of correspondence between symptoms and diagnostic
categories, we hypothesized that GIMCs would be more likely than MHCs to attribute
psychological causes and treatments to Gulf War veterans' unexplained physical
symptoms and that MHCs would be more likely than GIMCs to attribute physical
causes to the same symptoms and to recommend biomedical treatments.
PARTICIPANTS AND METHODS
Participants comprised GIMCs and MHCs at the Veterans Affairs Puget
Sound Health Care System, Seattle, and American Lake Divisions in Washington
State and the Veterans Affairs Medical Center in Portland, Ore. In November
1998, surveys were mailed to 400 providers in mental health clinics and 135
providers in general internal medicine clinics. Seventy-seven GIMCs (57%)
and 214 MHCs (54%) completed the survey. Participation of respondents was
anonymous. However, information was obtained on respondents' profession, primary
specialty, number of Gulf War veterans cared for in the past year, and sources
of information regarding Gulf War illness. Sample characteristics of each
group's professional training are shown in Table 1. Respondents reported obtaining information regarding the
etiology and treatment of Gulf War illness from newspapers (GIMCs, 64%; MHCs,
51%), professional journals (GIMCs, 57%; MHCs, 57%), patient reports (GIMCs,
58%; MHCs, 31%), television or radio (GIMCs, 48%; MHCs, 27%), and government
publications (GIMCs, 44%; MHCs, 58%). Mental health clinicians and GIMCs did
not differ with respect to the number of Gulf War veterans they treated in
the past year (mode, 1-10; range, 0 to >50).
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Table 1. Sample Characteristics of Professional Training
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SURVEY
The Clinician Beliefs Survey of Gulf War Symptoms consists of 19 self-report
questions designed to assess beliefs about etiology, clinical course, and
treatment in clinicians treating Gulf War veterans with chronic multisymptom
illness. The survey was derived from the earlier work of Turk and colleagues.17 On the cover page, respondents were asked to consider
the following: "Following service in the Persian Gulf, many veterans reported
symptoms that are sometimes referred to as Gulf War illness or Gulf War syndrome.
Veterans with this presentation often have complaints that include some combination
of the following: fatigue, joint pain, muscle pain, headaches, gastrointestinal
problems, rash, hair loss, and sleep disturbance or problems with concentration
or memory." Respondents were then asked to rate the degree that they agreed
or disagreed with statements concerning the etiology, clinical course, and
treatment of Gulf War illness on a 7-point Likert-type ordinal scale ranging
from -3 to +3: -3 indicates completely disagree; -2, mostly
disagree; -1, slightly disagree; 0, no opinion; 1, slightly agree; 2,
mostly agree; and 3, completely agree.
The final 2 questions on the survey were global measures designed to
assess providers' beliefs concerning the etiology and treatment of Gulf War
illness. The first question asked participants to "Rate the degree to which
you believe Gulf War illness is (1) a physical disorder exclusively, (2) mostly
a physical disorder, (3) an equal combination of physical and mental disorders,
(4) mostly a mental disorder, or (5) a mental disorder exclusively." The second
question asked respondents to "Rate the degree to which you believe Gulf War
illness, in general, is most effectively treated by (1) biological interventions
exclusively, (2) mostly biological interventions, (3) an equal combination
of biological and psychological interventions, (4) mostly psychological interventions,
or (5) psychological interventions exclusively." A copy of the instrument
is available on request.
STATISTICAL ANALYSIS
Bivariate relationships were tested for statistical significance using
2-tailed independent-samples t tests for comparisons
of continuous variables and  2 tests for categorical variables.
The criterion for statistical significance in all analyses was  = .05,
without adjustment for multiple comparisons.
RESULTS
Table 2 compares GIMCs and
MHCs on specific survey items arranged in content categories of etiology,
clinical course, and treatment. Compared with GIMCs, MHCs were significantly
more likely to agree that Gulf War–related symptoms result from contagious
agents such as viruses or bacteria, immunizations, exposure to toxins, chemical
weapons, or a combination of toxins and stress (P
< .05 for all). Conversely, GIMCs were significantly more likely than MHCs
to believe that symptoms were due to stress or posttraumatic stress disorder.
Neither group reported that symptoms were the result of compensation-seeking
behavior.
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Table 2. Comparison of Survey Item Scores by Discipline
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Compared with MHCs, GIMCs were significantly more likely to disagree
with the statements that the symptoms were contagious, permanent, life threatening,
or in need of additional medical tests by a specialist. General internal medicine
clinicians were significantly more likely than MHCs to agree that symptoms
are best explained by some known diagnosis other than Gulf War illness. Also,
MHCs were significantly more likely than GIMCs to agree that symptoms will
often return even after treatment and can be lessened by stress reduction.
Both MHCs and GIMCs disagreed with the belief that symptoms will go away without
treatment; however, disagreement with this belief was significantly stronger
in MHCs than GIMCs (Table 2).
The professional affiliations of the MHCs were diverse and included
clinicians with medicine-oriented training (psychiatrists, nurses, physician
assistants, and psychiatric nurse practitioners) and nonmedicine–oriented
training (psychologists, social workers, addictions therapists, and psychology
technicians) (Table 1). We therefore
assessed whether the direction of clinicians' responses remained consistent
when only physician MHCs were compared with physician GIMCs. In this analysis,
with a reduced sample size (33 MHCs and 43 GIMCs), the comparisons again revealed
statistically significant differences and trends consistent with the larger
sample. An additional analysis was performed to examine whether differences
existed in the beliefs of MHCs as a result of their professional training.
Medicine-oriented MHCs (n = 114) were compared with nonmedicine-oriented MHCs
(n = 84) on all survey items. Nonmedicine-oriented MHCs were significantly
more likely than medicine-oriented MHCs to believe that immunizations were
responsible for Gulf War–related symptoms (t187 = -2.53; P = .01) and that the symptoms
were life threatening (t187 = -2.71; P = .007). The groups did not differ in their responses
to any other items, suggesting relative homogeneity of beliefs within MHCs
independent of specialty training.
On the final 2 global questions, clinicians' beliefs were measured regarding
the etiology and treatment of Gulf War illness. These questions allowed respondents
to indicate whether they believed the cause and effective treatments for symptoms
were "mostly" or "exclusively" physical or mental or "an equal combination
of both." Less than 1% of respondents selected extreme response categories
of the scale (ie, "exclusively physical" and "exclusively mental"); therefore,
we collapsed the "mostly" and "exclusively" response choices to construct
a physical or biological score. Figure 1
depicts the disparity in beliefs between MHCs and GIMCs on the global item
measuring beliefs regarding the etiology of Gulf War illness. There was a
significant relationship between respondent condition (GIMCs vs MHCs) and
etiologic beliefs about Gulf War illness (21 =
5.73; P < .05). As illustrated in Figure 1, GIMCs were more likely than MHCs to rate Gulf War illness
as "a mental disorder," whereas MHCs were more likely than GIMCs to rate symptoms
as being due to "a physical disorder." Although a clear disparity existed
in the beliefs on the etiology of Gulf War illness between GIMCs and MHCs,
almost 50% of both samples endorsed the belief that symptoms resulted from
a combination of mental and physical disorders. Figure 2 depicts responses to the question concerning beliefs about
the most effective treatment for Gulf War illness. Similar to the results
regarding beliefs about etiology, there was a significant relationship between
respondent condition (GIMCs vs MHCs) and beliefs about effective treatments
for Gulf War illness (21 = 8.57; P < .01). Again, MHCs were more likely than GIMCs to endorse biological
interventions to treat symptoms, whereas GIMCs were more likely than MHCs
to endorse psychological interventions. Results from this question also revealed
that most MHCs and GIMCs similarly believed that treatment of Gulf War illness
should incorporate both psychological and biological interventions.
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Figure 1. Clinicians' attributions of the
etiology of "Gulf War illness." Values are percentages of agreement.
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Figure 2. Clinicians' beliefs about the
most effective treatment for "Gulf War illness." Values are percentages of
agreement.
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COMMENT
To our knowledge, this is the first study to examine clinician beliefs
regarding the etiology and treatment of the unexplained physical symptoms
popularly described as Gulf War illness. We found divergent beliefs between
GIMCs and MHCs regarding the etiology and treatment of these symptoms. As
hypothesized, GIMCs tended to view symptoms as psychological in origin and
requiring psychological treatments and MHCs tended to view symptoms as medical
in origin and most responsive to medical interventions. Specifically, MHCs
were more likely to endorse that symptoms were due to biological exposures
such as infection, toxic agents, chemical weapons, and immunizations; GIMCs
were more likely to believe that stress or posttraumatic stress disorder was
the cause of symptoms. Both clinician groups believed that treatment would
be necessary for symptom resolution, but MHCs were twice as likely to view
symptoms as permanent. Clinicians in both groups generally disagreed with
the beliefs that symptoms were contagious or indicative of compensation-seeking
behavior.
Indices of global beliefs demonstrated that MHCs were almost 2 times
more likely than GIMCs to assign a physical cause to Gulf War illness, whereas
GIMCs were 3 times more likely than MHCs to endorse a psychological etiology.
Similarly, MHCs were 3 times more likely than GIMCs to endorse biological
interventions, whereas GIMCs were almost 3 times more likely than MHCs to
endorse psychological interventions for the effective treatment of Gulf War
illness. The global questions also revealed that approximately 50% of MHCs
and GIMCs believed that Gulf War illness was the result of an equal combination
of physical and psychological causes. Similarly, greater than 60% of MHCs
and GIMCs endorsed equal use of biological and psychological interventions
when treating these symptoms. These results suggest that while a substantial
number of study participants believe that both psychiatric and biological
factors play a role in the etiology and treatment of Gulf War illness, important
differences in these beliefs exist between mental health and general internal
medicine clinicians.
These data support the hypothesis that clinicians, when dealing with
the medical uncertainty associated with idiopathic physical symptoms occurring
after Gulf War service, tend to invoke explanations outside the scope of their
usual clinical knowledge. The absence of scientific evidence about known causes
and treatments allows an opportunity for practitioners to make clinical decisions
based on personal beliefs and biases. We suspect that the medical merry-go-round
experienced by some Gulf War veterans with medically unexplained physical
symptoms might be exacerbated by treating clinicians' views of the pathogenesis
of Gulf War illness. When faced with so much clinical uncertainty, clinicians
defer to providers within other disciplines with the hope that they might
provide new information and treatment recommendations. A pattern of repeated
referrals in the face of medical uncertainty is likely to contribute to unnecessary
clinician visits, excessive medical testing and invasive procedures, and overprescription
of pharmaceutical treatments. The health care impact of divergent clinician
beliefs regarding symptom-based disorders might not be unique to unexplained
physical symptoms in Gulf War veterans. Similar patterns of referral and excessive
health care utilization have been described for other symptom-based disorders,
such as somatization disorder,18 and contribute
to high health care costs and preventable iatrogenesis.
Clinical uncertainty or ambiguity might be one reason clinicians struggle
in their communication and relationships with Gulf War veterans who have multiple
idiopathic physical symptoms. In a community primary care sample of patients
presenting with symptoms similar to those of Gulf War veterans, diagnostic
tests were performed in more than two thirds of the patients; however, an
"organic" etiology was demonstrated in only 16% of the patients.19
For the general medical practitioner, a patient with multiple physical symptoms
in the absence of clinically apparent physical examination signs or laboratory
findings often leaves a residual psychological explanation. For example, patients
with chronic pain or fatigue report that their physicians often refer them
for mental health evaluations with little or no explanation and even tell
them that their symptoms are "in their head."20-23
In addition, the fact that these patients are often frustrated and distressed
over their symptoms and their treatment might reinforce the medical provider's
perception that the symptoms have psychological origins. For the mental health
professional, patients with multiple physical symptoms might create a similar
sense of uncertainty. The mental health professional might fear that the medical
provider has overlooked a potentially serious medical explanation for the
physical symptoms, a perception that can be compounded when physical symptoms
are not readily identifiable as a mental disorder.
Some limitations should be considered when interpreting these findings.
Data were gathered from a convenience sample of Veterans Affairs clinicians
practicing in a single geographic region; therefore, the generalizability
of these findings to other regions or health care systems is uncertain. Case
vignettes were not used; therefore, clinicians' interpretations of Gulf War
illness might have varied. Findings are from a single period and might be
subject to time trends determined by such factors as recent media reports
and new research findings. Last, although the measure we used to determine
provider beliefs is simple, has reasonable face validity, and is based on
an existing measure used to determine patient beliefs regarding symptom-based
illness, it has not been carefully validated with our added modifications
or in clinician samples. Consequently, the clinical significance of some of
the differences detected is difficult to quantify with confidence; however,
the consistency in the direction of responses suggests that these differences
in beliefs might be important.
The lack of a clearly established etiology and pathophysiologic mechanism
for many of the symptoms seen in primary care highlights the limitations of
applying a strict biomedical model to clinical practice. Processes of health
care for Gulf War veterans and others with symptom-based disorders necessitate
collaborative approaches that place clinicians with contrasting views of these
conditions in regular proximity to one another for the purposes of building
interdisciplinary rehabilitative interventions, sharing ideas, dispelling
simplistic etiologic explanations, and attempting to optimize the consistency
of information communicated to patients by all clinicians.
AUTHOR INFORMATION
Accepted for publication December 11, 2000.
This project was supported by the Mental Illness Research, Education,
and Clinical Center award to Veterans Integrated Service Network-20, Seattle,
Wash.
Presented in part to The National Academies, Institute of Medicine,
Committee on Identifying Effective Treatments for Gulf War Veterans' Health
Problems, Washington, DC, August 14, 2000.
We thank Hollie Holmes for her efforts in the preparation of this manuscript
and Scott Parker, PhD, for statistical consultation.
The views expressed in this article are those of the authors and do
not reflect the official policy or position of Walter Reed Army Medical Center,
Uniformed Services University, the Department of the Army, the Department
of Defense, or the US government.
Corresponding author and reprints: Ralph D. Richardson, PhD (116
MHC), Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way,
Seattle, WA 98108 (e-mail: ralph{at}u.washington.edu).
From the Veterans Affairs Puget Sound Health Care System, Seattle,
Wash (Drs Richardson, McFall, and Hunt); the Department of Psychiatry and
Behavioral Sciences, University of Washington School of Medicine, Seattle
(Drs Richardson and McFall); the Department of Psychiatry, Uniformed Services
University, Bethesda, Md (Dr Engel); Deployment Health Clinical Center, Walter
Reed Army Medical Center, Washington, DC (Dr Engel); the Department of Psychology,
University of Arizona, Tucson, and the Center for Excellence, Substance Abuse
Treatment, Veterans Affairs Puget Sound Health Care System (Dr McKnight);
and the Veterans Affairs Medical Center, Portland, Ore (Dr Boehnlein).
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