Psychological Medicine

Original Articles

Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices

R. E. Taylora1 c1, T. Marshalla2, A. Manna3 and D. P. Goldberga3

a1 Barts and the London School of Medicine and Dentistry, Queen Mary, Charterhouse Square, London, UK

a2 London School of Hygiene and Tropical Medicine, Keppel Street, London, UK

a3 Institute of Psychiatry, De Crespigny Park, London, UK


Background In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor–patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment.

Method We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate.

Results Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79–5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23–33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05–3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67–33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented.

Conclusions Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

(Received November 02 2010)

(Revised July 05 2011)

(Accepted July 12 2011)

(Online publication August 31 2011)


c1 Address for correspondence: R. E. Taylor, Ph.D., Barts and the London School of Medicine and Dentistry, Queen Mary, Centre for Psychiatry, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK. (Email: