The way people think about illness and how they interpret illness-associated somatic symptoms seems to be a major determinant of health-care-seeking, illness-associated disability and coping behavior. In particular, this seems to be the case for the attribution of common somatic symptoms, such as abdominal pain, back pain, chest pain, or headache. These and other unexplained physical symptoms are key features of somatoform disorders in DSM-IV. Somatoform symptoms are common phenomena with base rates of above 30% for single symptoms [1]; the symptoms are associated with substantial disability and significant costs for the health care system.
Current concepts of somatoform disorders emphasize the role of causal illness attributions [2] and [3]. It is assumed that patients with somatoform symptoms have a tendency to use organically oriented causal attributions for common somatic complaints. However, empirical approaches to evaluate this assumption are rare.
Robbins and Kirmayer [4] investigated attributions of common somatic symptoms using the symptom interpretation questionnaire. They revealed three dimensions of causal attributions, namely, psychological, somatic, and normalizing attributions. Sensky et al. [5] could demonstrate that causal attributions about common somatic sensations are associated with the frequency of general practice visits. The most striking difference between high utilizers and low utilizers of the health care system was found on the dimension of normalizing attributions: Frequent attenders reported less normalizing explanations for common bodily sensations than the comparison group.
The cognitive representation of illness is typically conceptualized following Leventhal's self-regulatory model. Following his model, the Illness Perception Questionnaire (IPQ) was developed, which covers five dimensions: (1) “identity” of the illness comprises 12 symptom items; (2) the dimension “time line” includes items asking for the expected course (persisting, temporary, short-time); other dimensions are (3) “cause” of the symptoms (organic, psychological), (4) expected consequences of the illness, and (5) expected cure/control. These dimensions of the representation of illness seem to be stable features [6] and can predict other aspects of illness course and illness behavior [7].
To date, illness attribution is typically assessed two or three dimensionally. However, symptom attribution seems to be a multidimensional process with coexisting explanations for one and the same symptom. Therefore, we wanted to examine the multiplicity of causal illness attributions in somatoform disorders. We expected the following results:
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The more symptoms patients have, the more illness attributions they consider.
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Moreover, we expect that illness attributions are associated with comorbidity patterns: Patients with pure somatoform disorders are expected to show more organically oriented explanations for symptoms, while patients with somatoform and comorbid depressive disorders are expected to show more psychological explanations for the symptoms.
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Finally, we also wanted to address possible associations between illness attribution and several aspects of illness behavior. Therefore, it was necessary to assess illness behavior not as unidimensional, but as a multidimensional construct with aspects such as seeking diagnostic or treatment options, illness consequences, and others (see Ref. [8])
