Examining the effectiveness of different dental recall strategies on maintenance of optimum oral health: the INTERVAL dental recalls randomised controlled trial.

Objective To compare the clinical effectiveness of different frequencies of dental recall over a four-year period.Design A multi-centre, parallel-group, randomised controlled trial with blinded clinical outcome assessment. Participants were randomised to receive a dental check-up at six-monthly, 24-monthly or risk-based recall intervals. A two-strata trial design was used, with participants randomised within the 24-month stratum if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or six-month recall interval.Setting UK primary dental care.Participants Practices providing NHS care and adults who had received regular dental check-ups.Main outcome measures The percentage of sites with gingival bleeding on probing, oral health-related quality of life (OHRQoL), cost-effectiveness.Results In total, 2,372 participants were recruited from 51 dental practices. Of those, 648 were eligible for the 24-month recall stratum and 1,724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding on probing between intervention arms in any comparison. For those eligible for 24-month recall stratum: the 24-month versus six-month group had an adjusted mean difference of -0.91%, 95% CI (-5.02%, 3.20%); the 24-month group versus risk-based group had an adjusted mean difference of 0.07%, 95% CI (-3.99%, 4.12%). For the overall sample, the risk-based versus six-month adjusted mean difference was 0.78%, 95% CI (-1.17%, 2.72%). There was no evidence of a difference in OHRQoL (0-56 scale, higher score for poorer OHRQoL) between intervention arms in any comparison. For the overall sample, the risk-based versus six-month effect size was -0.35, 95% CI (-1.02, 0.32). There was no evidence of a clinically meaningful difference between the groups in any comparison in either eligibility stratum for any of the secondary clinical or patient-reported outcomes.Conclusion Over a four-year period, we found no evidence of a difference in oral health for participants allocated to a six-month or a risk-based recall interval, nor between a 24-month, six-month or risk-based recall interval for participants eligible for a 24-month recall. However, patients greatly value and are willing to pay for frequent dental check-ups.

Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations.

PURPOSE: The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation. METHODS: We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP's empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups. RESULTS: In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727). CONCLUSIONS: In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.

Prediction of nursery school-aged children who refuse fluoride varnish administration in a community setting: a Childsmile investigation.

BACKGROUND: Young children of pre-school age may find a minimal intervention (fluoride varnish application) difficult to tolerate. AIM: To determine the significant predictors for refusing a fluoride varnish application from child, parental and nurse behaviour factors. DESIGN: Data included videos from 238 children (52% female, aged 3-5 years) receiving a fluoride varnish application in a Scottish nursery school setting. The St Andrews Behavioural Interaction Scheme (SABICS) was used for video coding and retrieved child refusal status, initial anxious behaviour, and nurse behaviour. A parental survey collected parent's dental anxiety [Modified Dental Anxiety Scale (MDAS)] and the child's home behaviour [Strengths and Difficulties Questionnaire (SDQ)]. Child demographics, dental status, and previous varnish application experience were recorded. Multivariate binary logistic regression was applied to predict child refusal of the varnish application. RESULTS: The response rate was 79%. Twelve children refused. The significant predictors of varnish refusal included initial anxious child behaviour (ß = 5.14, P = 0.001), no previous varnish application (ß = -3.89, P = 0.04), and no nurse praise (ß = -1.06, P = 0.02). Information giving (P = 0.06) and reassurance (P = 0.08) were borderline significant. CONCLUSION: Initial anxiety behaviour, previous varnish experience, and not using praise by the nursing staff predicted fluoride varnish application refusal.

Measuring children's dental anxiety.

DATA SOURCES: Medline and the Social Science Index Citation databases were searched. STUDY SELECTION: Studies had to have used measures of dental anxiety completed by children themselves (≤16 years), been published in English and reported primary data. Non-validated measures, those using proxy measures and non-dentally specific measures were excluded. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently using a standardised form. Validity and reliability of the questionnaires were assessed, and measures were evaluated against a theoretical framework of dental anxiety. A qualitative summary of the measures is presented. RESULTS: Sixty studies met the inclusion criteria. These covered seven 'trait' and two 'state' measures of dental anxiety used to assess children's dental anxiety over the past decade. CONCLUSIONS: The findings from this systematic review can be used to help guide dental academics, clinicians, psychologists and epidemiologists to choose the most appropriate measure of dental anxiety for their intended use. Future work should involve evaluating the content and developmental validity of existing measures with further consideration given to the use of theoretical frameworks to develop this field.

Decayed and missing teeth and oral-health-related factors: predicting depression in homeless people.

OBJECTIVE: The objective of the study was to determine the effect of dental health status, dental anxiety and oral-health-related quality of life (OHRQoL) upon homeless people's experience of depression. METHODS: A cross-sectional survey was conducted on a sample of homeless people in seven National Health Service Boards in Scotland. All participants completed a questionnaire to assess their depression, dental anxiety and OHRQoL using reliable and valid measures. Participants had an oral examination to assess their experience of tooth decay (decayed and missing teeth). Latent variable path analysis was conducted to determine the effects of dental health status on depression via dental anxiety and OHRQoL using intensive resampling methods. RESULTS: A total of 853 homeless people participated, of which 70% yielded complete data sets. Three latent variables, decayed and missing teeth, dental anxiety (Modified Dental Anxiety Scale: five items) and depression (Center for Epidemiological Studies Depression Scale: two factors), and a single variable for OHRQoL (Oral Health Impact Profile total scale) were used in a hybrid structural equation model. The variable decayed and missing teeth was associated with depression through indirect pathways (total standardised indirect effects=0.44, P<.001), via OHRQoL and dental anxiety (χ²=75.90, df=40, comparative fit index=0.985, Tucker-Lewis index=0.977, root mean square error of approximation=0.051 [90% confidence interval: 0.037-0.065]). CONCLUSION: Depression in Scottish homeless people is related to dental health status and oral-health-related factors. Decayed and missing teeth may influence depression primarily through the psychological constructs of OHRQoL and, to a lesser extent, dental anxiety.

Systematic review of post-treatment psychosocial and behaviour change interventions for men with cancer.

OBJECTIVES: The psychosocial impacts of a cancer diagnosis include reduced quality of life, poorer inter-personal relationships, hopelessness and mental illness. Worse outcomes, including mortality rates have been found for single men with cancer compared with women and partnered men. The aim of this systematic review was to examine the effectiveness of post-treatment psychosocial and behaviour change interventions for adult men with cancer, in order to inform the development of an intervention. A focus on single men was intended. METHODS: Ten databases were searched via Ovid and Web of Science. Papers were systematically extracted by title, abstract and full paper according to the inclusion/exclusion criteria. Full papers were assessed by two authors. INCLUSION CRITERIA: participants at any stage of a cancer diagnosis, > or =50% male and aged 18+; psychosocial and/or behavioural post-treatment interventions, using any format; a one-three level of evidence. Couple/carer/family interventions were excluded. RESULTS: From 9948 studies initially identified, 11 were finally included in the review. They implemented cognitive behaviour therapy, hypnosis or psychoeducational interventions. All studies had some positive results, however, lack of reporting of intervention content and methodological issues limit the findings. No studies intervened with single men, and none provided comparative outcomes for marital status. CONCLUSIONS: Effectiveness of interventions was difficult to assess as, while all had benefits, their generalisability was limited due to methodological and reporting limitations. Improved reporting procedures are required to allow for replication.

The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age.

BACKGROUND: The Modified Dental Anxiety Scale (MDAS) is a brief, self-complete questionnaire consisting of five questions and summed together to produce a total score ranging from 5 to 25. It has reasonable psychometric properties, low instrumental effects and can be integrated into everyday dental practice as a clinical aid and screen for dental anxiety. The objectives were to (i) produce confirmatory evidence of reliability and validity for the MDAS, (ii) provide up-to-date UK representative norms for the general public to enable clinicians to compare their patients' scores, (iii) to determine the nature of the relationship between dental anxiety and age. METHODS: Telephone survey of a representative quota sample of 1000 UK adults (>18 years of age) conducted between 7-21 April, 2008. RESULTS: Attrition of potential participants was high in the recruitment process, although bias was minimal. Estimated proportion of participants with high dental anxiety (cut-off score = 19) was 11.6%. Dental anxiety was four times greater in the youngest age group (18-39 yrs) compared to older participants (60+ yrs), controlling for sex, social class and self-reported dental visiting behaviour confirming previous developed-world reports. CONCLUSION: The scale's psychometrics is supportive for the routine assessment of patient dental anxiety to compare against a number of major demographic groups categorised by age and sex. Dental anxiety was high in younger compared to older people.

A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age.

BACKGROUND: The development of dental anxiety in children is poorly understood. AIMS: The aims of this study were to measure changes in dental anxiety over time and to examine the relationship between anxiety, dental care, and other factors. DESIGN: A prospective cohort study of children in the north-west of England followed from 5 to 9 years of age. The participants were clinically examined and their parents completed the same questionnaire at 5 and 9 years. RESULTS: The majority (54.3%N = 38) of participants who were anxious at 5 years were no longer anxious at 9 years, but a large proportion of children who were anxious at 5 remained anxious at 9 years of age (45.7%N = 32). During the follow-up period, a larger proportion of children developed anxiety (11.7%N = 85) than the proportion of children who were reported as being anxious at baseline (8.8%N = 70). At 9 years of age, dental anxiety was significantly associated with girls; parental anxiety; a history of extraction; and irregular, asymptomatic dental visiting. These factors were also significantly associated with dental anxiety at 5 years old. CONCLUSIONS: Dental anxiety was cumulative in the study population over time, and its development influenced by multiple variables. Results suggest that adverse conditioning and vicarious learning are both important in the development of this condition.

Primary care consultations about medically unexplained symptoms: how do patients indicate what they want?

BACKGROUND: Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs. OBJECTIVE: To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention. DESIGN: Prospective naturalistic study. Before consultation, patients indicated what they wanted from it using a self-report questionnaire measuring patients' desire for: emotional support, explanation and reassurance, and physical investigation and treatment. Their speech during consultation was audio-recorded, transcribed and coded utterance-by-utterance. Multilevel regression analysis tested relationships between what patients sought and what they said. PARTICIPANTS: Patients (N = 326) consulting 33 GPs about symptoms that the GPs designated as MUS. RESULTS: Patients who wanted emotional support spoke more about psychosocial problems, including psychosocial causes of symptoms and their need for psychosocial help. Patients who wanted explanation and reassurance suggested more physical explanations, including diseases, but did not overtly request explanation. Patients' wish for somatic intervention was associated only with their talk about details of such interventions and not with their requests for them. CONCLUSIONS: In general, patients with medically unexplained symptoms provide many cues to their desire for emotional support. They are more indirect or guarded in communicating their desire for explanation and somatic intervention.

Fear of recurrence and psychological distress in head and neck cancer patients and their carers.

BACKGROUND: Fear of recurrence (FOR) has been increasingly recognised as an issue of significant burden for most cancer patients, and has been associated with psychological morbidity and reduced quality of life. More recently, the impact of recurrence fears has been indicated in the families of cancer patients. However, there has been a lack of prospective research. AIM: To systematically examine distress and illness concerns among patient-carer dyads. METHODS: A multi-centre prospective study of head and neck cancer patients and their carers (patients, n=101; carers, n=101), surveyed at two time-points following diagnosis. RESULTS: Carers recorded higher recurrence concerns on average than the patient group (p<0.001). A predictive path model of patient and carer self-reports of distress and FORs was explored, with an excellent overall fit of the final model (chi(2)=15.4, df=12, p=0.22, Comparative Fit Index (CFI)=0.994, Root Mean Square Estimate of Approximation (RMSEA)=0.053). CONCLUSIONS: The preliminary results establish that early fears and distress within individuals govern later reports on these same attributes, but that there is some weak evidence of influence from one attribute to another within and across individuals in the dyad. Future prospective dyadic research is warranted to ascertain the level of these fears over an extended time and their relationship to patient and carer adaptation. Intervention may be needed to reduce this disease concern to a manageable level at an early stage of the illness trajectory.

A qualitative evaluation of patient experiences when diagnosed with oral cancer recurrence.

Loco-regional recurrence after radical primary treatment of oral cancer is associated with poor prognosis and major patient and career distress. The patient's psychosocial response to recurrence is underreported in the literature. This is one of the few papers to address in detail this stage in a patient's cancer journey. Qualitative methodology was used. Patients were recruited over a 13-month period. Analysis of recorded transcripts from 9 patients suggested that their illness experience and psychological response to diagnosis were multifaceted. Six key themes were identified, which were subdivided into 23 categories. Themes included emotional reactions, reevaluation, active coping strategies, life changes, support, and improvement in relationships. Emotional reactions ranged from shock and devastation, to fear and uncertainty, to hopelessness, to shame, to denial. Not all reactions were negative, and more positive experiences such as new found openness and improvement in relationships were expressed. There is heightened emotional vulnerability, and this leads to potentially difficult management issues among clinicians and members of the multidisciplinary team. Extreme sensitivity is required by all the individuals involved in providing healthcare at this acute time of patient and career distress.

The missing member of the head and neck multidisciplinary team: the psychologist. Why we need them.

PURPOSE OF REVIEW: The aim of this article is to present the latest published material to demonstrate the service activity for the head and neck cancer team. RECENT FINDINGS: There is a growing literature confirming the importance of many psychological issues that impact on the experience of the patient following diagnosis and treatment of head and neck cancer. Although there may be some recognition by some members of the multidisciplinary team to involve psychological services there is now ample evidence from the results of this literature to argue that the psychologist should feature as a full member of the multidisciplinary team. Activities would include formal assessment of psychological features of the patient and carer, interpretation of psychometric data including distress and quality of life inventories, design and implementation of interventions and supervisory support for the work pressures experienced by the multidisciplinary team. SUMMARY: The care of the head and neck patient involves a large variety of psychosocial factors. Many of these issues require formal assessment and interpretation that the professional psychologist can input into the care programmes for these patients.

Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms.

OBJECTIVE: We tested the theory that general practitioners (GPs) offer somatic intervention to patients with medically unexplained symptoms (MUS) as a defensive response to patients' dependence. We predicted that GPs most likely to respond somatically after patients indicated symptomatic or psychosocial needs had attachment style characterised by negative models of self and others. METHOD: Twenty-five GPs identified 308 patients presenting MUS and indicated their own models of self and others. Consultations were audio recorded and coded speech-turn-by-speech-turn. We modeled the probability of GPs proposing somatic intervention on any turn as a function of their models of self and other and the number of prior turns containing symptomatic or psychosocial presentations. RESULTS: Prior psychosocial presentations decreased the likelihood of GPs offering somatic intervention. The decrease was greatest in GPs with most positive models of self and, contrary to prediction, least positive models of others. The positive relationship between prior somatic presentations and the likelihood that GPs offered somatic intervention was unrelated to either model. CONCLUSION: Findings are incompatible with our theory that GPs propose somatic interventions defensively. Instead, GPs may provide somatic intervention because they value patients (positive model of others) but devalue their own psychological skills (negative model of self).

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

OBJECTIVE: Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style. METHODS: Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses. RESULTS: Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others. CONCLUSIONS: From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as "confrontation." Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention.

OBJECTIVE: In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation. METHODS: Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion). RESULTS: Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients' and doctors' psychosocial talk. The relationship with doctors' psychosocial talk was accounted for by patients' psychosocial talk. Contrary to predictions, doctors' normalization was inversely associated with somatic intervention and physical explanations had no effect. CONCLUSION: Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients' psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention.

Do dental anxiety questionnaires raise anxiety in dentally anxious adult patients? A two-wave panel study.

OBJECTIVE: To test whether or not dentally anxious patients attending the dentist for an appointment become more anxious when completing a dental anxiety questionnaire. BASIC RESEARCH DESIGN: Patients were initially screened to include only those who were dentally anxious. A pre- and post-test was planned with the completion of the Modified Dental Anxiety Scale (MDAS) questionnaire as the intervention. CLINICAL SETTING: Two dental access centres in the North West of England. PARTICIPANTS: Initially, 583 patients were screened. Of these, 182 (31%) were found to be dentally anxious and were recruited into the study. MAIN OUTCOME MEASURES: State-Trait Anxiety Inventory Scale Short Form. RESULTS: State anxiety did not change with the completion of the MDAS questionnaire in either designated dental phobics (MDAS >or=19) or those classified as non-phobics (MDAS <19). CONCLUSIONS: The MDAS can be used to assess dental anxiety without raising anxiety in patients with or without self-reported dental phobia.

Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure.

OBJECTIVE: We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients' attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians. METHODS: Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn. Hierarchical logistic regression analysis modeled the probability of the physician proposing medical care as a function of the quantity of patients' speech of specific kinds that preceded it. RESULTS: Whether physicians proposed medical care was unrelated to patients' attributions to disease or demands for treatment. Proposals of explicitly somatic responses (drugs, investigation or specialist referral) became more likely after patients had elaborated their symptoms and less likely after patients indicated psychosocial difficulties. Proposals of a further primary care consultation were responses simply to lengthening consultation. CONCLUSIONS: The findings are incompatible with the influential assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, the reason why many of these patients receive high levels of medical care should be sought by investigating the motivations behind physicians' responses to patients' symptom presentation.

Comparison of the domains of anxiety and mood of the University of Washington Head and Neck Cancer Questionnaire (UW-QOL V4) with the CES-D and HADS.

BACKGROUND: Version 4 of the University of Washington Head and Neck Cancer Questionnaire (UW-QOLv4) includes items on mood and anxiety. The aim of this study was to compare the responses to these single items with the Centre for Epidemiology Studies Depression Scale (CES-D) and the Hospital Anxiety Depression Scale (HADS). METHODS: A cross-sectional postal survey was undertaken in April 2003. The survey was composed of all patients treated for oral and oropharyngeal squamous cell carcinoma between 1992 and 2002 who were alive and disease free. RESULTS: We distributed 306 questionnaires; there were 197 replies (65%) from 110 male and 87 female patients. Most patients reported relatively little depression, with 170 of 190 (89%) reporting a HADS depression score of less than 11. Similarly, most patients were not anxious, with 158 of 183 (86%) reporting a HADS anxiety score of less than 11. UW-QOL mood, UW-QOL anxiety, HADS anxiety, HADS depression, and CES-D scores were all moderately intercorrelated (Spearman correlations from 0.39-0.68 ignoring the signs, all p < .001). The UW-QOL mood correlated with the scores and "case-ness" categories of the HADS depression and CES-D scales, whereas the UW-QOL anxiety correlated with the scores and "case-ness" of the HADS anxiety. CONCLUSIONS: Questions on mood and anxiety can help identify significant psychological morbidity, taking a score of less than 75 for UW-QOL mood and less than 70 for UW-QOL anxiety. This could be used to trigger formal psychological assessment and with a view to possible therapeutic intervention.

Psychological responses and support needs of patients following head and neck cancer.

The patient with head and neck (H&N) cancer is prone to psychological distress immediately following diagnosis and during the treatment phase. Lowered mood is typical and tends to extend beyond the treatment phase. There is little evidence for a specific treatment method predicting a characteristic psychological response. Rather, patients' reactions vary widely according to fears of recurrence, health beliefs, personality, coping and available support. Patient reports of quality of life show a return to pre-treatment status after a year but are determined to some degree by initial depression levels and dispositional factors such as optimism. Information provided to patients (e.g. leaflets, booklets of written guidance) by specialist treatment centres about the disease and its management require sustained effort in their design and distribution. Our understanding of patient responses to this disease has improved and has assisted in the development of psychological interventions. Controlled trials will provide important evidence of the components, effects and sustainability of these experimental programmes, and improve overall care plans for this often neglected patient group.

What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?

OBJECTIVE: We tested predictions that patients with medically unexplained symptoms (MUS) want more emotional support and explanation from their general practitioners (GPs) than do other patients, and that doctors find them more controlling because of this. DESIGN: Thirty-five doctors participated in a cross-sectional comparison of case-matched groups. Three hundred fifty-seven patients attending consecutively with MUS were matched for doctor and time of attendance with 357 attending with explained symptoms. Patients self-reported the extent to which they wanted somatic intervention, emotional support, explanation and reassurance. Doctors rated their perception of patients' influence on the consultation. Predictions were tested by multilevel analyses. RESULTS: Patients with MUS sought more emotional support than did others, but no more explanation and reassurance or somatic intervention. A minority of doctors experienced them as exerting more influence than others. The experience of patient influence was related to the patients' desire for support. CONCLUSIONS: Future research should examine why GPs provide disproportionate levels of somatic intervention to patients who seek, instead, greater levels of emotional support.