51
|
Yahalom J. Social Factors of Health-Seeking Behavior: On Medical Treatment for Elders With Dementia in Oaxaca, Mexico. JOURNAL OF HUMANISTIC PSYCHOLOGY 2020. [DOI: 10.1177/0022167819899591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article presents data on family caregiving for elders with dementia in Oaxaca, Mexico. Drawing on a year of ethnographic research, this article explores how caregivers engage in health-seeking behaviors and how they choose between biomedical and traditional medical alternatives. While caregivers are primarily concerned to maintain elders’ health, decisions about which medical providers to (not) consult invoke broader social factors that go beyond their relationships with elders, and concern socioeconomic realms of power, as well as broader ideals concerning local tradition and its maintenance in the contemporary world.
Collapse
Affiliation(s)
- Jonathan Yahalom
- University of California, Los Angeles, CA, USA
- U.S. Department of Veterans Affairs, Los Angeles, CA, USA
| |
Collapse
|
52
|
Hulgaard DR, Rask CU, Risor MB, Dehlholm G. Illness perceptions of youths with functional disorders and their parents: An interpretative phenomenological analysis study. Clin Child Psychol Psychiatry 2020; 25:45-61. [PMID: 31079473 DOI: 10.1177/1359104519846194] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Functional disorders, defined as disorders with no clear medical explanation, are common and impose a significant burden on youths, their families, healthcare services and society as a whole. Currently, the literature describes resistance among patients and their families towards psychological symptom explanations and treatments. More knowledge about the thoughts and understandings of youths with functional disorders and their parents is needed. The aim of this study was to explore the illness perceptions of youths with severe functional disorders and their parents. METHODS A qualitative interview study using interpretative phenomenological analyses. The study included 11 youths aged 11-15 years with functional disorders and their parents, where interviews were performed at the point of referral from a somatic to a psychiatric treatment setting. RESULTS Analyses identified three main themes. Themes 1(Ascribing identity to the disorder) and 2 (Monocausal explanations) explore key elements of the participants' illness perceptions, and theme 3 (Mutable illness perceptions) explores how illness perceptions are influenced by experiences from healthcare encounters. CONCLUSIONS The label 'functional disorder' was poorly integrated in the illness perceptions of the youths and their parents. Participants used a monocausal and typically physical explanation rather than a multicausal biopsychosocial explanation for their symptoms.
Collapse
Affiliation(s)
- Ditte Roth Hulgaard
- Child and Adolescent Psychiatry, Department of Clinical Research, University of Southern Denmark, Denmark
| | - Charlotte Ulrikka Rask
- Research Unit, Centre for Child and Adolescent Psychiatry, Central Denmark Region, Aarhus University Hospital, Denmark
| | - Mette Bech Risor
- General Practice Research Unit, Department of Community Medicine, UiT, The Arctic University of Norway, Norway
| | - Gitte Dehlholm
- Child and Adolescent Psychiatry, Department of Clinical Research, University of Southern Denmark, Denmark
| |
Collapse
|
53
|
Abstract
In the US, disagreement over the biological basis of "chronic Lyme disease" has resulted in the institutionalization of two standards of care: "mainstream" and "Lyme-literate." For mainstream physicians, chronic Lyme disease is a "medically unexplained illness" that presents with an abundance of "symptoms" in the absence of diagnostic "signs." For Lyme-literate physicians, and complementary and alternative medicine practitioners more generally, symptoms alone provide sufficient evidence for medical explanation. Drawing upon ethnographic research among mainstream and Lyme-literate physicians, I suggest that medically unexplained illness is not a biomedical anomaly but an intrinsic feature of biomedicine.
Collapse
Affiliation(s)
- Abigail A Dumes
- Department of Women's Studies, University of Michigan , Ann Arbor, Michigan, USA
| |
Collapse
|
54
|
Kvamme MF, Wang CEA, Waage T, Risør MB. Careful expressions of social aspects: How local professionals in high school settings, municipal services, and general practice communicate care to youth presenting persistent bodily complaints. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:1175-1184. [PMID: 30969453 DOI: 10.1111/hsc.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 06/09/2023]
Abstract
Persistent health complaints pose communicative dilemmas in care encounters, adversely affecting patient experiences and pathways. Little is known about the impact and role of professionals in encounters with young people with incipient, debilitating, and persistent symptoms. This study aims to explore communicative dilemmas and the role of language in care provided by local professionals in high school settings, municipal services, and general practice to young people presenting persistent bodily complaints. The study is based on in-depth individual interviews conducted from April to July 2016 with 12 professionals identified and selected during anthropological multi-sited fieldwork in a Norwegian community. We identify two modalities of what we have chosen to call 'careful expression', used as strategies across professions to overcome communicative dilemmas. Professionals reflexively and pragmatically negotiated with the powers of language to influence illness experience and to enact empowered young subjects. These insights may prove relevant for future studies of care encounters while also indicating a critical attitude to institutional logics that affect care responses.
Collapse
Affiliation(s)
- Maria F Kvamme
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Catharina E A Wang
- Department of Psychology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Trond Waage
- Department of Social Sciences, Visual Cultural Studies, UiT The Arctic University of Norway, Tromsø, Norway
| | - Mette B Risør
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
55
|
Ball S, Howes C, Affleck A. Functional symptoms in dermatology: Part 2. Clin Exp Dermatol 2019; 45:20-24. [DOI: 10.1111/ced.14064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 11/29/2022]
Affiliation(s)
- S.L. Ball
- Department of Dermatology Royal Infirmary of Edinburgh Edinburgh UK
| | - C. Howes
- Department of Liaison Psychiatry Western General Hospital Edinburgh UK
| | - A.G. Affleck
- Department of Dermatology Ninewells Hospital Dundee UK
| |
Collapse
|
56
|
Ball SL, Howes C, Affleck AG. Functional symptoms in dermatology: Part 1. Clin Exp Dermatol 2019; 45:15-19. [PMID: 31456245 DOI: 10.1111/ced.14063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
Functional - or somatoform - symptoms are those that arise with no proven organic pathology. Also known as 'medically unexplained' symptoms, they can present in any medical speciality, including dermatology. Mucocutaneous pain syndromes and functional pruritus are two examples of functional disorders encountered by dermatologists. Patients presenting with somatoform symptoms have paradoxically complex and often subjectively severe symptomatology, yet minimal abnormalities on clinical examination or investigation. Such disparity can be frustrating and distressing for patients and clinicians alike, and there are many pitfalls regarding overinvestigation and misleading communication. However, with an honest and open approach - sometimes requiring collaboration with psychological services - management of functional symptoms can be effective, and patients can be successfully rehabilitated.
Collapse
Affiliation(s)
- S L Ball
- Department of Dermatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Howes
- Department of Liaison Psychiatry, Western General Hospital, Edinburgh, UK
| | - A G Affleck
- Department of Dermatology, Ninewells Hospital, Dundee, UK
| |
Collapse
|
57
|
Řiháček T, Čevelíček M. Common therapeutic strategies in psychological treatments for medically unexplained somatic symptoms. Psychother Res 2019; 30:532-545. [PMID: 31345126 DOI: 10.1080/10503307.2019.1645370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: Medically unexplained somatic symptoms (MUSS) represent a frequent complaint in health care services. While psychological treatments have demonstrated some effect in patients with MUSS, further progress may be achieved by a synthesis of clinical strategies used in diverse treatment models. The aim of this study was to identify clinical strategies shared across multiple psychological treatments intended for the treatment of adult patients with MUSS. Method: Descriptions of psychological treatments for patients with MUSS were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. N = 135 resources met inclusion criteria and were subjected to qualitative analysis. Results: Similarities across treatments were captured in 8 broad categories and 18 subcategories that covered aspects of the therapeutic relationship, specific skills (bodily, emotional, and relational) for patients to develop, search for the meaning of symptoms, and the orientation on life beyond symptoms. Conclusions: Despite the differences in technique, it was possible to identify common therapeutic strategies in psychological treatments for patients with MUSS. These overarching treatment strategies, many of which have already obtained empirical support, may inspire further research and the development of comprehensive treatments with enhanced efficacy. Limitations of the present study include the lack of focus on specific syndromes.
Collapse
Affiliation(s)
- Tomáš Řiháček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| | - Michal Čevelíček
- Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic
| |
Collapse
|
58
|
Poloni N, Caselli I, Ielmini M, Mattia M, De Leo A, Di Sarno M, Isella C, Bellini A, Callegari C. Hospitalized Patients with Medically Unexplained Physical Symptoms: Clinical Context and Economic Costs of Healthcare Management. Behav Sci (Basel) 2019; 9:E80. [PMID: 31331103 PMCID: PMC6680508 DOI: 10.3390/bs9070080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022] Open
Abstract
Medically Unexplained Physical Symptoms (MUPS) are physical symptoms without a medical explanation. This study collected data from hospitalized patients presenting MUPS, aiming to draw a clinical and socio-demographic profile of patients with MUPS, to explore psychopathological correlations of Somatic Symptoms Disorder (SSD) diagnosis, and to estimate economic costs related to hospital management for MUPS. The cross-sectional study consisted in the evaluation of data referring to hospitalized patients admitted between 2008 and 2018 in a teaching hospital in Northern Italy. A total of 273 patients presenting MUPS have been hospitalized. The sample showed a prevalence of female, married and employed patients. The most frequent wards involved are Neurology, Internal Medicine and Short Unit Stay. The most common symptoms found are headache, pain, syncope and vertigo. There is no evidence that a history of medical disease is associated with a diagnosis of SSD. A personality disorder diagnosis in patients with MUPS was associated with increased probability of having a diagnosis of SSD. A marginally significant positive association emerged with anxiety disorders, but not with depressive disorder. The overall estimated cost of hospitalization for patients with MUPS is 475'409.73 €. The study provides the investigation of a large number of patients with MUPS and a financial estimate of related hospitalization costs.
Collapse
Affiliation(s)
- Nicola Poloni
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy
| | - Ivano Caselli
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy
| | - Marta Ielmini
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy
| | - Michele Mattia
- Family Therapy Center, Via San Salvatore 7, 6902 Lugano, Switzerland
| | - Alessandra De Leo
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy
| | - Marco Di Sarno
- Department of Psychology, University of Milan-Bicocca, Piazza dell'Ateneo Nuovo 1, 20126 Milan (MI), Italy
| | - Celeste Isella
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy
| | - Alessandro Bellini
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy
| | - Camilla Callegari
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Viale Luigi Borri 57, 21100 Varese (VA), Italy.
| |
Collapse
|
59
|
Pitron V, Ranque B, Vulser H, Rotgé JY, Limosin F, Lemogne C. [Functional somatic syndromes: A comprehensive cognitive model]. Rev Med Interne 2019; 40:466-473. [PMID: 31160125 DOI: 10.1016/j.revmed.2019.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 03/25/2019] [Accepted: 04/12/2019] [Indexed: 12/16/2022]
Abstract
Functional somatic syndromes are frequent in general and specialized medicine practices. Several treatments can be useful. However, the treatment program is often hampered by patients' reluctance to acknowledge the diagnosis because of erroneous lay representations. Recent advances in cognitive science offer a new understanding of the pathophysiology of functional somatic disorders, making this diagnosis more acceptable for patients and caregivers. Simply explained with practical examples, the Bayesian model in particular provides some insights into the underlying cognitive mechanisms of functional somatic syndromes and their treatments. Advantages of this approach are twofold: it is consistent with current scientific knowledge and it can facilitate the physician-patient relationship.
Collapse
Affiliation(s)
- V Pitron
- UMR 8129, ENS/EHESS/CNRS, IEC, PSL, Instit Jean-Nicod, 29, rue d'Ulm, 75005 Paris, France; Service de psychiatrie et d'addictologie de l'adulte et du sujet âgé, hôpitaux universitaires Paris Ouest, AP-HP, 20, rue Leblanc, 75015 Paris, France.
| | - B Ranque
- Service de médecine interne, hôpitaux universitaires Paris Ouest, AP-HP, 20, rue Leblanc, 75015 Paris, France; Faculté de médecine, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École de médecine, 75005 Paris, France
| | - H Vulser
- Service de psychiatrie et d'addictologie de l'adulte et du sujet âgé, hôpitaux universitaires Paris Ouest, AP-HP, 20, rue Leblanc, 75015 Paris, France; Faculté de médecine, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École de médecine, 75005 Paris, France
| | - J Y Rotgé
- Service de psychiatrie d'adultes, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Équipe neurosciences sociales et affectives, ICM CRICM, CNRS UMR 7225, Inserm S 1127, institut du cerveau et de la moelle épinière, 75013 Paris, France; Sorbonne université, 75006 Paris, France
| | - F Limosin
- Service de psychiatrie et d'addictologie de l'adulte et du sujet âgé, hôpitaux universitaires Paris Ouest, AP-HP, 20, rue Leblanc, 75015 Paris, France; Faculté de médecine, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École de médecine, 75005 Paris, France; Inserm U894, centre psychiatrie et neuroscience, 102-108, rue de la Santé, 75014 Paris, France
| | - C Lemogne
- Service de psychiatrie et d'addictologie de l'adulte et du sujet âgé, hôpitaux universitaires Paris Ouest, AP-HP, 20, rue Leblanc, 75015 Paris, France; Faculté de médecine, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École de médecine, 75005 Paris, France; Inserm U894, centre psychiatrie et neuroscience, 102-108, rue de la Santé, 75014 Paris, France
| |
Collapse
|
60
|
Hulme K, Little P, Burrows A, Julia A, Moss‐Morris R. Subacute fatigue in primary care - two sides of the story. Br J Health Psychol 2019; 24:419-442. [PMID: 30848557 PMCID: PMC6519220 DOI: 10.1111/bjhp.12361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 01/31/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Fatigue is a common symptom in primary care. Chronic fatigue research highlights the value of preventing chronicity, but little research has investigated the early, subacute stage of the fatigue trajectory (<3 months). We aimed to examine patient and general practitioner (GP) perspectives of subacute fatigue in primary care: (1) to gain a better understanding of fatigue during this stage and (2) to explore how management could be improved. DESIGN A qualitative study design was used. In-depth, semi-structured telephone interviews were conducted with 14 patients and 14 GPs (non-dyadic), recruited from 19 primary care practices. METHODS Interview transcripts were thematically analysed. Initially, patient and GP accounts were analysed separately, before themes were merged to identify shared and independent perspectives. RESULTS Three main themes were identified. Within these, subthemes from patients', GPs', or shared patient/GP perspectives emerged. The main themes encompassed the following: (1) Change from normal - the impact of fatigue; (2) The challenges of managing fatigue; and (3) The consultation GPs' knowledge was often not reflected in patients' accounts, even for those reporting positive experiences, suggesting knowledge was not effectively translated. CONCLUSIONS Some findings, such as impact, mirror those described in chronic fatigue. New insights into early-stage fatigue management also arose, including mismatches in patient and GP perceptions on negative tests and not re-presenting. These highlight the need for better communication and shared understanding. GPs should pre-emptively present a biopsychosocial model of fatigue and keep communication channels open, particularly in the light of negative physiological tests. Statement of contribution What is already known on this subject? Patients with chronic fatigue retrospectively report lack of understanding from GPs in early stage of illness. Little research has investigated the early stages of the fatigue trajectory. What does this study add? Consequences of an episode of subacute fatigue are similar to those reported for CFS. There is discordance between GPs' positive view of negative tests and patients' need for explanation of symptoms. The length of appointments is a significant barrier for creating shared understanding.
Collapse
Affiliation(s)
- Katrin Hulme
- Health Psychology SectionInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonUK
| | - Paul Little
- Primary Care and Population SciencesFaculty of MedicineUniversity of SouthamptonUK
| | - Abigail Burrows
- Health Psychology SectionInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonUK
| | - Anna Julia
- Health Psychology SectionInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonUK
| | - Rona Moss‐Morris
- Health Psychology SectionInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonUK
| |
Collapse
|
61
|
Youth With Chronic Pain and a History of Adverse Childhood Experiences in the Context of Multidisciplinary Pain Rehabilitation. Clin J Pain 2019; 35:420-427. [DOI: 10.1097/ajp.0000000000000686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
62
|
Tallman PS. Water insecurity and mental health in the Amazon: Economic and ecological drivers of distress. ECONOMIC ANTHROPOLOGY 2019. [DOI: 10.1002/sea2.12144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
63
|
Selinheimo S, Vasankari T, Jokela M, Kanervisto M, Pirkola S, Suvisaari J, Paunio T. The association of psychological factors and healthcare use with the discrepancy between subjective and objective respiratory-health complaints in the general population. Psychol Med 2019; 49:121-131. [PMID: 29554990 DOI: 10.1017/s0033291718000582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND We examined the prevalence of self-perceived respiratory symptoms (SRS) in the absence of any objective findings of respiratory pathology, and the association of such prevalence with psychological factors and healthcare use in the general population. METHODS The study was conducted among a nationally representative sample of Finnish adults (BRIF8901). Respiratory functioning was measured by a spirometry test. Structured questionnaires were used to measure SRS, physician visits and psychological factors of alexithymia, sense of coherence, illness worry and common mental disorders. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder, determined in a diagnostic interview, were excluded, giving a sample comprising 4544 participants. RESULTS Twenty-six per cent of the general population and 36% of those with no diagnosed severe psychiatric disorder or respiratory disease experienced SRS despite a normal spirometry result. Psychological factors were associated with SRS (0.0001 < p < 0.032), and on the number of physician visit explaining 42.7% of the difference in visits between individuals with and without SRS, respectively. Illness worry was associated most strongly with SRS [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.19-1.41, p < 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32-1.38, p < 0.00001), even after several adjustments. CONCLUSIONS Respiratory symptoms without objective findings are common in the general population. The study results underline the role of psychological factors in the reporting of respiratory symptoms and the associated medical burden, thereby indicating the functional nature of the symptomatology.
Collapse
Affiliation(s)
| | | | - Markus Jokela
- Department of Psychology and Logopedics,Faculty of Medicine,University of Helsinki,Helsinki,Finland
| | | | - Sami Pirkola
- Health Sciences, andUniversity Hospital Psychiatric Department,University of Tampere,Tampere,Finland
| | - Jaana Suvisaari
- Department of Health,National Institute for Health and Welfare,Helsinki,Finland
| | - Tiina Paunio
- Finnish Institute of Occupational Health,Helsinki,Finland
| |
Collapse
|
64
|
Kealy D, Rice SM, Ogrodniczuk JS, Spidel A. Childhood trauma and somatic symptoms among psychiatric outpatients: Investigating the role of shame and guilt. Psychiatry Res 2018; 268:169-174. [PMID: 30029065 DOI: 10.1016/j.psychres.2018.06.072] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 05/25/2018] [Accepted: 06/22/2018] [Indexed: 11/26/2022]
Abstract
Previous research suggests a link between experiences of childhood maltreatment and adult somatic symptom distress. Contributing mechanisms, however, are not yet well understood. It is possible that shame and guilt may function as mediators in the relationship between childhood trauma and adult somatic distress. The present study was developed to investigate the relationship between childhood maltreatment and adult somatic distress, including the potential mediating role of shame and guilt, among psychiatric outpatients. Using data from a sample of 99 Canadian psychiatric outpatients, mediation models with shame and guilt as parallel mediators were evaluated for relationships between childhood emotional abuse, sexual abuse, emotional neglect, and somatic symptoms. Controlling for current depressive symptoms, a significant indirect effect was found for the relationship between emotional abuse and shame, but not guilt, in contributing to somatic symptoms. A similar result was obtained regarding the mediating role of shame in the relationship between emotional neglect and somatic symptoms. Mediation was non-significant regarding childhood sexual abuse, which was directly related to somatic distress after controlling for depressive symptoms. The findings provide further evidence of the link between childhood trauma and somatic symptom distress, with shame as a mechanism for the effects of emotional abuse and neglect.
Collapse
Affiliation(s)
- David Kealy
- Department of Psychiatry, University of British Columbia, #420-5950 University Blvd, Vancouver, BC V6T 1Z3, Canada.
| | - Simon M Rice
- Orygen, Centre for Youth Mental Health, University of Melbourne, 35 Poplar Rd, Parkville, VIC 3052, Australia
| | - John S Ogrodniczuk
- Department of Psychiatry, University of British Columbia, #420-5950 University Blvd, Vancouver, BC V6T 1Z3, Canada
| | - Alicia Spidel
- White Rock/South Surrey Mental Health and Substance Use Services, 15521 Russell Avenue, White Rock, BC, Canada V4B 2R4
| |
Collapse
|
65
|
Østbye SV, Wang CEA, Granheim IPH, Kristensen KE, Risør MB. Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms. Int J Ment Health Syst 2018; 12:52. [PMID: 30258491 PMCID: PMC6151926 DOI: 10.1186/s13033-018-0232-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 09/19/2018] [Indexed: 12/03/2022] Open
Abstract
Background Early adolescence is considered a critical period for the development of chronic and recurrent medically unexplained symptoms (MUS), and referrals and system-initiated patient trajectories often lead to an excess of examinations and hospitalizations in the cross-section between mental and somatic specialist care for this group of patients. Dimensions of the relationship and communication between clinician and patient are shown in primary care studies to be decisive for subsequent illness pathways, often creating adverse effects, but knowledge on clinical communication in specialist care is still scarce. Methods This study explores communicative challenges specific to clinical encounters between health professionals and adolescent patients in specialist care, as presented through interviews and focus group data with highly experienced specialists working in adolescent and child services at a Norwegian university hospital. Results The results are presented in a conceptual model describing the epistemological and methodological paradoxes inherent in the clinical uncertainty of MUS. Within these paradoxes, the professionals try to solve the dilemmas by being creative in their communication strategies; applying metaphors and other rhetorical devices to explain complex ideas; creating clinical prototypes as a way to explain symptoms and guide them in clinical action; relying on principles from patient-centered care involving empathy; and trying to balance expertise and humility. Conclusion The challenges in communication arise as a result of opposing discourses on biomedicine, family, health and adolescence that create dilemmas in everyday clinical work. By moving away from a positivist and biomedical framework towards an interpretive paradigm, where culturally derived and historically situated interpretations are used to understand the social life-world of the patient, one can create a more humane health service in accordance with ideals of patient-centered care.
Collapse
Affiliation(s)
- Silje Vagli Østbye
- 1Department of Psychology, Faculty of Health, UiT-Arctic University of Norway, Tromsø, Norway
| | | | | | | | - Mette Bech Risør
- 4Department of Community Medicine, General Practice Research Unit, Faculty of Health, UiT-Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
66
|
McKernan LC, Finn MTM, Carr ER. Personality and Affect When the Central Nervous System is Sensitized: An Analysis of Central Sensitization Syndromes in a Substance Use Disorder Population. Psychodyn Psychiatry 2018; 45:385-409. [PMID: 28846511 DOI: 10.1521/pdps.2017.45.3.385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Functional somatic syndromes, or more recently termed central sensitivity syndromes (CSS), comprise a significant portion of the chronic pain population. Although it is evident that personality is intricately related to the pain experience, it has not been widely studied. This article examines the impact of CSS on the clinical presentation of individuals presenting to treatment for a substance use disorder (SUD), with an emphasis on personality and emotional functioning. We examined personality profiles of individuals presenting to treatment with SUD between three groups: those with a CSS (n = 30), non-CSS chronic pain (n = 79), and no pain (n = 232). Based on previous research and a psychodynamic conceptualization of CSS, we hypothesized that predictors of the presence of a CSS in this sample would be higher rates of overall anxiety, traumatic stress, perfectionistic traits, and a need for interpersonal closeness. Logistic regression analyses did not support our hypothesis. Exploratory analyses indicated which personality traits most strongly predicted the presence of CSS. We discuss these findings using descriptive psychopathology literature, with recommendations for future research.
Collapse
Affiliation(s)
- Lindsey C McKernan
- Assistant Clinical Professor, Vanderbilt University School of Medicine, Osher Center of Integrative Medicine
| | - Michael T M Finn
- Doctoral Candidate in Clinical Psychology, The University of Tennessee, Knoxville
| | - Erika R Carr
- Assistant Professor, Director of Inpatient Psychology, Yale University School of Medicine
| |
Collapse
|
67
|
Geraghty KJ, Blease C. Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter. Disabil Rehabil 2018; 41:3092-3102. [PMID: 29929450 DOI: 10.1080/09638288.2018.1481149] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective: Despite the growing evidence of physiological and cellular abnormalities in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), there has been a strong impetus to tackle the illness utilizing a biopsychosocial model. However, many sufferers of this disabling condition report distress and dissatisfaction following medical encounters. This review seeks to account for this discord.Methods: A narrative review methodology is employed to synthesize the evidence for potential iatrogenesis.Results: We identify seven potential modalities of iatrogenesis or harm reported by patients:difficulties in reaching an acceptable diagnosis;misdiagnosis, including of other medical and psychological conditions;difficulties in accessing the sick role, medical care and social support;high levels of patient dissatisfaction with the quality of medical care;negative responses to controversial therapies (cognitive behavioral therapy and graded exercise therapy);challenges to the patient narrative and experience;psychological harm (individual and collective distress).Conclusion: The biopsychosocial framework currently applied to ME/CFS is too narrow in focus and fails to adequately incorporate the patient narrative. Misdiagnosis, conflict, and harm are observable outcomes where doctors' and patients' perspectives remain incongruent. Biopsychosocial practices should be scrutinized for potential harms. Clinicians should consider adopting alternative patient-centred approaches.Implications for rehabilitationPatients with ME/CFS may report or experience one or more of the modalities of harms and distress identified in this review.It is important health and rehabilitation professionals seek to avoid and minimize harms when treating or assisting ME/CFS patients.There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients.The 'biopsychosocial framework' applied in clinical practice promotes treatments such as cognitive behavioral therapy and exercise therapy, however, the evidence for their success is contested and many patients reject the notion their illness is perpetuated by dysfunctional beliefs, personality traits, or behaviors.Health professionals may avoid conflict and harm causation in ME/CFS by adopting more concordant 'patient-centred' approaches that give greater prominence to the patient narrative and experience of illness.
Collapse
Affiliation(s)
- Keith J Geraghty
- Division of Health Services Research and Population Health, University of Manchester, Centre for Primary Care, Manchester, UK
| | - Charlotte Blease
- Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
68
|
Attoe C, Lillywhite K, Hinchliffe E, Bazley A, Cross S. Integrating mental and physical health care: the mind and body approach. Lancet Psychiatry 2018; 5:387-389. [PMID: 29429950 DOI: 10.1016/s2215-0366(18)30044-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Chris Attoe
- The Mind and Body Programme, King's Health Partners, Guy's Hospital, London SE1 9RT, UK.
| | - Kate Lillywhite
- The Mind and Body Programme, King's Health Partners, Guy's Hospital, London SE1 9RT, UK
| | - Eliza Hinchliffe
- The Mind and Body Programme, King's Health Partners, Guy's Hospital, London SE1 9RT, UK
| | - Anna Bazley
- The Mind and Body Programme, King's Health Partners, Guy's Hospital, London SE1 9RT, UK
| | - Sean Cross
- The Mind and Body Programme, King's Health Partners, Guy's Hospital, London SE1 9RT, UK; Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| |
Collapse
|
69
|
Sowińska A, Czachowski S. Patients' experiences of living with medically unexplained symptoms (MUS): a qualitative study. BMC FAMILY PRACTICE 2018; 19:23. [PMID: 29394880 PMCID: PMC5797356 DOI: 10.1186/s12875-018-0709-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 01/24/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with medically unexplained symptoms (MUS) are common in primary care, and pose a communicative and therapeutic challenge to GPs. Although much has been written about GPs' frustration and difficulties while dealing with these patients, research presenting the patients' perspectives on MUS still seems to be scarce. Existing studies have demonstrated the patients' desire to make sense of symptoms, addressed the necessity for appropriate and acceptable explanation of MUS, and revealed stigmatization of patients with symptoms of mental origin. Treatment in primary care should focus on the patient's most essential needs and concerns. The objective of this paper is to explore Polish patients' perspectives on living with MUS. METHODS A qualitative content analysis of 20 filmed, semi-structured interviews with patients presenting MUS (8 men and 12 women, aged 18 to 57) was conducted. All patients were diagnosed with distinctive somatoform disorders (F45), and presented the symptoms for at least 2 years. The interviews were transcribed verbatim and analysed independently by two researchers. RESULTS Four major themes emerged: (1) experiences of symptoms; (2) explanations for symptoms; (3) coping; (4) expectations about healthcare. Within the first theme, the patients identified the following sub-themes: persistence of symptoms or variability, and negative emotions. Patients who observed that their symptoms had changed over time were better disposed to accept the existence of a relationship between the symptoms and the mind. The second theme embraced the following sub-themes: (1) personal explanations; (2) social explanations; (3) somatic explanations. The most effective coping strategies the patients mentioned included: the rationalization of the symptoms, self-development and ignoring the symptoms. The majority of our respondents had no expectations from the healthcare system, and stated they did not use medical services; instead, they admitted to visiting psychologists or psychiatrists privately. CONCLUSION Patients with MUS have their own experiences of illness. They undertake attempts to interpret their symptoms and learn to live with them. The role of the GP in this process is significant, especially when access to psychological help is restricted. Management of patients with MUS in the Polish healthcare system can be improved, if access to psychologists and psychotherapists is facilitated and increased financial resources are allocated for primary care. Patients with MUS can benefit from a video/filmed consultation with a follow-up analysis with their GP.
Collapse
Affiliation(s)
- Agnieszka Sowińska
- Department of English, Nicolaus Copernicus University, ul. W. Bojarskiego 1, 87-100, Toruń, Poland.
| | - Sławomir Czachowski
- Department of Psychology and Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, ul. Gagarina 39, 87-100, Toruń, Poland
| |
Collapse
|
70
|
Sempértegui GA, Knipscheer JW, Bekker MHJ. Development and evaluation of diversity-oriented competence training for the treatment of depressive disorders. Transcult Psychiatry 2018; 55:31-54. [PMID: 28948878 PMCID: PMC5777556 DOI: 10.1177/1363461517725224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Studies in Europe indicate that some ethnic minorities have higher rates of mental disorders and less favorable treatment outcomes than their counterparts from majority groups. To date, efforts regarding training to reduce disparities have mainly focused on ethnocultural competences of therapists, with less attention paid to other aspects of diversity, such as sex/gender and socioeconomic status. In this study, we aim to determine the effectiveness of a population-specific, diversity-oriented competence training designed to increase therapists' competencies to integrate aspects of diversity features in clinical assessment, diagnosis, and treatment of depressive disorders in Turkish- and Moroccan-Dutch patients. A group of 40 therapists were location-based assigned to either training or a control condition (no training). Self-reported diversity competence, a knowledge test, and therapists' satisfaction with training were used to monitor the training and to measure competence levels at baseline, post-training, and three-month follow-up. Attitude-awareness and knowledge components of the self-reported diversity competence and test-measured knowledge increased in the training condition. Most gains remained stable at follow-up except test-measured knowledge after controlling for percentage of ethnic minority patients in caseload. There were no changes regarding therapists' self-reported skills. Therapists expressed medium-high satisfaction with the training, acknowledging the relevance of diversity competence for their daily practice. Future training must ensure better adjustment to therapists' pre-existing knowledge and be followed by long-term efforts to maintain competence levels and enhance competence transfer within teams.
Collapse
|
71
|
Dinos S, Ascoli M, Owiti JA, Bhui K. Assessing explanatory models and health beliefs: An essential but overlooked competency for clinicians. BJPSYCH ADVANCES 2018. [DOI: 10.1192/apt.bp.114.013680] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
SummaryExplanatory models of illness – the way people perceive, interpret and respond to it – are mediated not only by the illness itself, but also by cultural and social contexts. This article discusses recent evidence showing how the exploration of explanatory models can help to shape treatment and outcomes for some of the most common categories of mental illness, and presents case studies illustrating dilemmas clinicians face when their explanatory models differ from those of their patients. It concludes with recommendations on how a culturally sensitive clinical approach based on the exploration of explanatory models during assessment and treatment can be used as an effective way of dealing with the complexity of patients' and families' needs.Learning Objectives• Appreciate the use of explanatory models in clinical practice• Understand the relevance of explanatory models in relation to specific diagnostic categories of mental illness• Recognise that dilemmas may arise if the explanatory models of the clinician and the patient differ, and be able to manage this tension
Collapse
|
72
|
Abstract
SummaryThis article discusses a cognitive–behavioural therapy (CBT) approach to the treatment of medically unexplained symptoms that is based on the ‘five areas’ model of CBT. We describe a typical course of therapy and some of the common problems encountered during treatment. Emphasis is placed on the practical management of these conditions, and the focus is on symptoms as opposed to cause. We believe that this approach is widely applicable and could be used in a large range of settings to tackle these debilitating conditions. In writing this article we intended to provide an overview of patients with medically unexplained symptoms. The article would be of interest to staff within liaison psychiatry departments looking to set up a medically unexplained symptoms service and general psychiatry teams who may have contact with patients presenting with somatic symptoms. Psychiatric teams without access to a liaison department may also find this article interesting.
Collapse
|
73
|
Abstract
Adult patients with medically unexplained symptoms (somatisation) in primary care are numerous and make disproportionately high demands on health services. Most of these individuals are open to the suggestion that their illness reflects psychological needs. Empowering explanations from doctors can enable patient and doctor to work collaboratively in managing the problem and can reduce healthcare contacts. Parental medically unexplained symptoms, sexual and physical abuse in childhood and childhood neglect are associated with a greater risk of medically unexplained symptoms in adulthood. The overall prognosis for the majority of primary care patients with medically unexplained symptoms is very good. The two most common approaches to dealing with medically unexplained symptoms in primary care are stepped-care approaches and teaching general practitioners new skills to manage consultations more effectively.
Collapse
|
74
|
Hulme K, Chilcot J, Smith MA. Doctor-patient relationship and quality of life in Irritable Bowel Syndrome: an exploratory study of the potential mediating role of illness perceptions and acceptance. PSYCHOL HEALTH MED 2017; 23:674-684. [PMID: 29260889 DOI: 10.1080/13548506.2017.1417613] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder characterised by unpredictable bowel symptoms. These can be difficult to manage, consequently impacting quality of life (QoL). In addition, a strained doctor-patient relationship is independently reported in the qualitative literature. Given the doctor is often the first port of call for people with IBS, a difficult relationship may influence subsequent IBS management. Research suggests illness perceptions are important in determining IBS outcomes in therapy; however, their association with doctor-patient relationship and QoL is yet to be investigated. This exploratory study aimed to investigate the association between these constructs in IBS, as well as potential mediation by illness perceptions. Online questionnaires measuring doctor-patient relationship, illness perceptions, acceptance and QoL, were completed by 167 participants who reported an IBS diagnosis (144 female, mean age = 44.22 years, SD = 15.91 years). Bootstrapped pathway analysis was used to model the relationship and mediation effects. There was a significant positive correlation between patient-doctor relationship and QoL, r = .258, n = 167, p = .001. There was a significant indirect effect between doctor-patient relationship and QoL through illness coherence and acceptance (bootstrapped estimate = .058, 95%CI Lower-Upper = .02, .095, p = .002). No other indirect effects were observed in combination with good fit indices for the other illness perceptions. Findings suggest a doctor-patient relationship which fosters mutual understanding and helps patients make sense of symptoms, increases their ability to manage their IBS in a psychologically flexible manner, subsequently helping them maintain their QoL.
Collapse
Affiliation(s)
- Katrin Hulme
- a Psychology Department , Northumbria University , Newcastle , UK.,b Health Psychology Section, Psychology Department , Institute of Psychiatry, King's College London , London , UK
| | - Joseph Chilcot
- b Health Psychology Section, Psychology Department , Institute of Psychiatry, King's College London , London , UK
| | - Michael A Smith
- a Psychology Department , Northumbria University , Newcastle , UK.,c Faculty of Health and Medical Sciences , University of Western Australia , Perth , Australia
| |
Collapse
|
75
|
Cooper A, Abbass A, Town J. Implementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting. J Clin Med 2017; 6:jcm6120109. [PMID: 29186054 PMCID: PMC5742798 DOI: 10.3390/jcm6120109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 12/24/2022] Open
Abstract
Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.
Collapse
Affiliation(s)
- Angela Cooper
- Centre for Emotions & Health, Departments of Psychiatry & Family Medicine, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| | - Allan Abbass
- Centre for Emotions & Health, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| | - Joel Town
- Centre for Emotions & Health, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| |
Collapse
|
76
|
Okland TS, Gonzalez JR, Ferber AT, Mann SE. Association Between Patient Review of Systems Score and Somatization. JAMA Otolaryngol Head Neck Surg 2017; 143:870-875. [PMID: 28617903 DOI: 10.1001/jamaoto.2017.0671] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Somatization is a condition in which psychological distress is manifested by medically unexplained symptoms, and it is prevalent in all medical specialties, including otolaryngology. Recognition of somatization can be difficult, and there are limited methods available. Objectives To determine whether patients with somatization respond differently to the review of systems (ROS) portion of the patient interview and whether the ROS can be used to identify patients with somatization. Design, Setting, and Participants A retrospective review of medical records of 2120 consecutive consultations of English- or Spanish-speaking patients aged 18 to 89 years who presented to the otolaryngology clinic from January 1, 2014, to November 10, 2015, was conducted to compare how the ROS of patients with chief complaints associated with somatization (group B: globus sensation, dizziness, and tinnitus) differs from those with symptoms more often associated with objective findings (group A: nasal obstruction, hoarseness, and hearing loss); a total of 605 patients were included. Objective clinical findings after physical examination and related testing were reviewed and classified as either significant, marginal, or absent. Current or past psychiatric comorbidities were also examined. Main Outcomes and Measures Number of affirmative responses on a standardized, 69-point ROS was recorded as a ROS score (ROSS). Objective clinical findings, symptoms, and psychiatric comorbidities were recorded. Results Of the 605 patients included in the analysis, 346 (57.2%) were women, and the mean (SD) age was 51.6 (15.7) years. Among patients with medically unexplained symptoms (median, 11; range, 0-39), the ROSS was higher compared with those with objective clinical findings (median, 6; range, 0-31) (median difference, 4; 95% CI, 3 to 6). Group A (hoarseness, nasal obstruction, and hearing loss: median ROSS, 6, range, 0-41) exhibited lower ROSS than group B (dizziness, globus sensation, and tinnitus: median ROSS, 9; range, 0-39) (median difference, -2; 95% CI -3 to -1). Psychiatric comorbidity (median, 10; range, 0-41) was associated with higher ROSS than patients without psychiatric comorbidity (median, 5.5; range, 0 to 36) (median difference, 5; 95% CI, 3 to 6). Conclusions and Relevance The manner in which patients respond to a standardized ROS differs in those with medically unexplained symptoms and in those with psychiatric disease. The ROS offers information beyond the actual systems review, and may be useful in the identification of somatization.
Collapse
Affiliation(s)
| | | | - Alexander Thomas Ferber
- Medical Scientist Training Program, Department of Physiology & Biophysics, University of Colorado School of Medicine, Aurora
| | - Scott Edward Mann
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora.,Division of Otolaryngology, Denver Health Medical Center, Denver
| |
Collapse
|
77
|
Blease C, Carel H, Geraghty K. Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome. JOURNAL OF MEDICAL ETHICS 2017; 43:549-557. [PMID: 27920164 DOI: 10.1136/medethics-2016-103691] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/30/2016] [Accepted: 11/11/2016] [Indexed: 06/06/2023]
Abstract
Chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Fricker's concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret clinical studies of treatments. Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors (and medical students) display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by healthcare professionals, and many patients vocally oppose the effectiveness, and the conceptualisation, of their illness as psychologically treatable. We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice (2007). We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the (often unintentional) marginalisation of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness.
Collapse
Affiliation(s)
- Charlotte Blease
- School of Philosophy, University College Dublin, Dublin, Ireland
- Program in Placebo Studies, Harvard Medical School, Harvard University, Boston, USA
| | - Havi Carel
- School of Philosophy, University of Bristol, Bristol, UK
| | - Keith Geraghty
- Centre for Primary Care, University of Manchester, Manchester, UK
| |
Collapse
|
78
|
The association between multiple chemical sensitivity and mental illness: Evidence from a nationally representative sample of Canadians. J Psychosom Res 2017; 99:40-44. [PMID: 28712429 DOI: 10.1016/j.jpsychores.2017.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/17/2017] [Accepted: 06/05/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The goal of the present study was to investigate the association between multiple chemical sensitivity (MCS) and major depressive disorder (MDD), generalized anxiety disorder (GAD), MDD and GAD comorbidity (MDD+GAD), severe distress, and positive mental wellbeing. METHODS This cross-sectional investigation was carried out using the 2012 Canadian Community Health Survey - Mental Health Component. The study population consisted of 21,977 individuals aged 20 and older, from Canada's ten provinces. Odds ratios were computed using multinomial logistic regression to calculate estimates of the association between MCS and mental illness. All analyses were weighted to take into account the complex survey design. RESULTS Individuals with MCS had 2.37 (1.55, 3.64) times greater odds of MDD, 3.09 (1.80, 5.30) times greater odds of MDD+GAD, and 2.60 (1.67, 4.07) times greater odds of severe distress. No association between MCS and GAD was observed. A sex difference was observed with males with MCS having lower odds of positive mental wellbeing, whereas no association was observed in females. CONCLUSIONS The present study findings supported an association between MCS and mental illness. The causal mechanism supporting this association remains unclear.
Collapse
|
79
|
Abstract
Purpose
The purpose of this paper is to summarise practice-based evidence from an analysis of outcomes from a county-wide pilot study of a specialised primary care clinic employing an original approach for patients with medically unexplained symptoms (MUS). Conditions with persistent bodily symptoms for which tests and scans come back negative are termed MUS. Patients are generic, high health-utilising and for most there is no effective current treatment pathway. The solution is a proven service based on proof of concept, cost-effectiveness and market research studies together with practice-based evidence from early adopters. The research was transferred from a university into a real-world primary care clinical service which has been delivering in two clinical commissioning groups in a large county in England.
Design/methodology/approach
Clinical data calculated as reliable change from the various clinics were aggregated as practice-based evidence pre- and post-intervention via standardised measurements on anxiety, depression, symptom distress, functioning/activity, and wellbeing. It is not a research paper.
Findings
At post-course the following percentages of people report reliable improvement when compared to pre-course: reductions in symptom distress 63 per cent (39/62), anxiety 42 per cent (13/31) and depression 35 per cent (11/31); increases in activity levels 58 per cent (18/31) and wellbeing 55 per cent (17/31) and 70 per cent felt that they had enough help to go forward resulting in the self-management of their symptoms which decreases the need to visit the GP or hospital.
Research limitations/implications
Without a full clinical trial the outcomes must be interpreted with caution. There may be a possible Hawthorne or observer effect.
Practical implications
Despite the small numbers who received this intervention, preliminary observations suggest it might offer a feasible alternative for many patients with MUS who reject, or try and find unsatisfying, cognitive behaviour therapy.
Social implications
Many patients suffering MUS feel isolated and that they are the only one for whom their doctor cannot find an organic cause for their condition. The facilitated group has a beneficial effect on this problem, for example they feel a sense of belonging and sharing of their story.
Originality/value
The BodyMind Approach is an original intervention mirroring the new wave of research in neuroscience and philosophy which prides embodiment perspectives over solely cognitive ones preferred in the “talking” therapies. There is a sea change in thinking about processes and models for supporting people with mental ill-health where the need to include the lived body experience is paramount to transformation.
Collapse
|
80
|
Cathébras P. La perspective de la médecine centrée sur la personne : une condition nécessaire pour apporter une réponse adéquate aux syndromes somatiques fonctionnels. Rev Med Interne 2017. [DOI: 10.1016/j.revmed.2017.03.340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
81
|
McWilliams LA. Adult attachment insecurity is positively associated with medically unexplained chronic pain. Eur J Pain 2017; 21:1378-1383. [PMID: 28418216 DOI: 10.1002/ejp.1036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Attachment insecurity (i.e. anxiety in relationships and/or discomfort in close relationships) is associated with self-reports of physical symptoms, medically unexplained symptoms and health conditions involving pain. Medically unexplained chronic pain (MUCP) may represent a particularly severe form of symptom reporting that is also characteristic of individuals with insecure attachment. This study investigated relationships between adult attachment style ratings and past-year MUCP in a sample of the general U.S. population and the ability of attachment style ratings to account for variance in past-year MUCP beyond that accounted for by potential confounders. METHOD Data from the National Comorbidity Survey Replication (N = 5645) were used. Attachment was assessed with an interview-administered version of a commonly used self-report measure of secure, anxious and avoidant attachment. MUCP was assessed with a brief interview. Depressive and anxiety disorders were included as covariates and were assessed with a fully structured interview based on DSM-IV criteria. RESULTS The past-year prevalence of MUCP was 2.45% (95% CI = 2.07-2.83). The two insecure attachment styles (i.e. anxious and avoidant) were positively associated with MUCP. These associations remained statistically significant after adjusting for demographic variables and depressive and anxiety disorders. When the two insecure attachment styles were considered together, only avoidant attachment remained significantly associated with MUCP. CONCLUSION Attachment insecurity ratings were positively associated with past-year MUCP and remained so after statistically adjusting for depressive and anxiety disorders. Further research aimed at understanding the mechanism(s) responsible for the association between attachment insecurity and MUCP is warranted. SIGNIFICANCE Consistent with earlier research regarding transient physical symptoms, medically unexplained chronic pain was associated with attachment insecurity. Understanding the mechanisms responsible for this association could guide treatment innovations.
Collapse
Affiliation(s)
- L A McWilliams
- Department of Psychology, University of Saskatchewan, SK, Canada
| |
Collapse
|
82
|
Fernando A, Attoe C, Jaye P, Cross S, Pathan J, Wessely S. Improving Interprofessional Approaches to Physical and Psychiatric Comorbidities Through Simulation. Clin Simul Nurs 2017. [DOI: 10.1016/j.ecns.2016.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
83
|
Roth EG, Girling LM, Chard S, Wallace BH, Eckert JK. Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication. HEALTH COMMUNICATION 2017; 32:502-508. [PMID: 27295568 PMCID: PMC5572677 DOI: 10.1080/10410236.2016.1140270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.
Collapse
Affiliation(s)
- Erin G. Roth
- University of Maryland Baltimore County, Center for Aging Studies, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| | - Laura M. Girling
- University of Maryland Baltimore County, Center for Aging Studies, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| | - Sarah Chard
- University of Maryland Baltimore County, Center for Aging Studies, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
- University of Maryland Baltimore County, Sociology & Anthropology Department, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| | - Brandy Harris Wallace
- University of Maryland Baltimore County, Center for Aging Studies, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
- University of Maryland Baltimore County, Sociology & Anthropology Department, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| | - J. Kevin Eckert
- University of Maryland Baltimore County, Center for Aging Studies, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
- University of Maryland Baltimore County, Sociology & Anthropology Department, PUP, 1000 Hilltop Circle, Baltimore, MD 21250, USA
| |
Collapse
|
84
|
Johansen ML, Risor MB. What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies. PATIENT EDUCATION AND COUNSELING 2017; 100:647-654. [PMID: 27894609 DOI: 10.1016/j.pec.2016.11.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/02/2016] [Accepted: 11/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To gain a deeper understanding of challenges faced by GPs when managing patients with MUS. METHODS We used meta-ethnography to synthesize qualitative studies on GPs' perception and management of MUS. RESULTS The problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem. CONCLUSION For GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education. PRACTICE IMPLICATIONS Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines.
Collapse
Affiliation(s)
- May-Lill Johansen
- Dept. of Community Medicine, UiT The Arctic University of Norway, Tromso, Norway.
| | - Mette Bech Risor
- Dept. of Community Medicine, UiT The Arctic University of Norway, Tromso, Norway; General Practice Research Unit, UiT The Arctic University of Norway, Tromso, Norway
| |
Collapse
|
85
|
Hulme K, Deary V, Dogan S, Parker SM. Psychological profile of individuals presenting with chronic cough. ERJ Open Res 2017; 3:00099-2016. [PMID: 28344979 PMCID: PMC5357770 DOI: 10.1183/23120541.00099-2016] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/06/2017] [Indexed: 01/01/2023] Open
Abstract
Chronic refractory cough (CRC) is a common problem in respiratory clinics. Adverse effects on quality of life are documented in the literature, but relatively little is known about the underlying psychological factors in this patient population. We aimed to investigate the association of psychological factors with chronic cough, comparing CRC to explained cough and non-cough groups. 67 patients attending a specialist cough clinic (CRC, n=25; explained cough, n=42) and 22 non-cough individuals participated. All participants completed the Hospital Anxiety & Depression Scale, Big Five Inventory (Personality), Chalder Fatigue Scale and Patient Health Questionnaire-15. Cough patients also completed the Illness Perception Questionnaire-Revised. Appropriate statistical analyses were used to compare participant groups. Chronic refractory coughers displayed significantly higher levels of anxiety, depression, fatigue and somatic physical symptoms than non-cough participants. Compared to explained coughers, there were higher depression and fatigue scores and significantly more negative illness representations (specifically, strong beliefs regarding negative consequences, lower illness coherence and higher emotional representations). "Explained" coughers reported significantly increased fatigue and somatic symptoms in comparison to non-coughers. The prevalence of fatigue, low mood, negative illness beliefs and increased physical symptom reporting should be considered in consultations and in developing novel interventions for CRC patients.
Collapse
Affiliation(s)
- Katrin Hulme
- Respiratory Medicine, North Tyneside Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK; Health Psychology, Guy's Hospital, King's College London, London, UK; Health Psychology, Staffordshire University, Stoke-on-Trent, UK
| | - Vincent Deary
- Psychology Dept, Northumbria University, Newcastle, UK
| | - Sian Dogan
- Respiratory Medicine, North Tyneside Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Sean M Parker
- Respiratory Medicine, North Tyneside Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| |
Collapse
|
86
|
Bullington J, Cronqvist A. Group supervision for healthcare professionals within primary care for patients with psychosomatic health problems: a pilot intervention study. Scand J Caring Sci 2017; 32:108-116. [PMID: 28156013 DOI: 10.1111/scs.12436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/10/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND In primary health care, efficacious treatment strategies are lacking for these patients, although the most prominent symptoms accounting for consultation in primary care often cannot be related to any biological causes. AIM The aim was to explore whether group supervision from a specific phenomenological theory of psychosomatics could provide healthcare professionals treating patients with psychosomatic health issues within primary care a deeper understanding of these conditions and stimulate profession-specific treatment strategies. Our research questions were as follows: (i) What is the healthcare professionals' understanding of psychosomatics before and after the intervention? (ii) What are the treatment strategies for this group of patients before and after the intervention? METHODS The study was an explorative qualitative intervention pilot study. The six participants from a primary healthcare setting in a medium-sized city in Sweden participated in the study. A supervision group was formed, based on a mix of professions, age, gender and years of clinical experience. Supervision consisted of one 75-minutes meeting every month during the course of 6 months. Participants were interviewed before and after the supervision intervention. FINDINGS The study showed two distinct categories emerged from the data. One category of healthcare professionals espoused a psycho-educative approach, while the other lacked a cohesive approach. The supervision improved the second category of healthcare professionals' understanding of psychosomatics. The psycho-educative group did not change their understanding of psychosomatics, although they felt strengthened in their approach by the supervision. Profession-specific strategies were not developed. IMPLICATIONS This pilot study indicates that a relatively short supervision intervention can aid clinicians in their clinical encounters with these patients; however, further research is necessary to ascertain the value of the specific phenomenologically based supervision intervention.
Collapse
Affiliation(s)
- Jennifer Bullington
- Department of Health Care Science, Ersta Sköndal University College, Stockholm, Sweden
| | - Agneta Cronqvist
- Department of Health Care Science, Ersta Sköndal University College, Stockholm, Sweden
| |
Collapse
|
87
|
Abstract
Diagnoses in medicine are often taken to serve as explanations of patients' symptoms and signs. This article examines how they do so. I begin by arguing that although some instances of diagnostic explanation can be formulated as covering law arguments, they are explanatory neither in virtue of their argumentative structures nor in virtue of general regularities between diagnoses and clinical presentations. I then consider the theory that medical diagnoses explain symptoms and signs by identifying their actual causes in particular cases. While I take this to be largely correct, I argue that for a diagnosis to function as a satisfactory causal explanation of a patient's symptoms and signs, it also needs to be supplemented by understanding the mechanisms by which the identified cause produces the symptoms and signs. This mechanistic understanding comes not from the diagnosis itself, but rather from the theoretical framework within which the physician operates.
Collapse
Affiliation(s)
- Hane Htut Maung
- Department of Politics, Philosophy, and Religion, Lancaster University, Lancaster, LA1 4YL, UK.
| |
Collapse
|
88
|
Morton L, Elliott A, Cleland J, Deary V, Burton C. A taxonomy of explanations in a general practitioner clinic for patients with persistent "medically unexplained" physical symptoms. PATIENT EDUCATION AND COUNSELING 2017; 100:224-230. [PMID: 27569909 DOI: 10.1016/j.pec.2016.08.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/14/2016] [Accepted: 08/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To develop a taxonomy of explanations for patients with persistent physical symptoms. METHODS We analysed doctors' explanations from two studies of a moderately-intensive consultation intervention for patients with multiple, often "medically-unexplained," physical symptoms. We used a constant comparative method to develop a taxonomy which was then applied to all verbatim explanations. RESULTS We analysed 138 explanations provided by five general practitioners to 38 patients. The taxonomy comprised explanation types and explanation components. Three explanation types described the overall structure of the explanations: Rational Adaptive, Automatic Adaptive, and Complex. These differed in terms of who or what was given agency within the explanation. Three explanation components described the content of the explanation: Facts - generic statements about normal or dysfunctional processes; Causes - person-specific statements about proximal or distal causes for symptoms; Mechanisms - processes by which symptoms arise or persist in the individual. Most explanations conformed to one type and contained several components. CONCLUSIONS This novel taxonomy for classifying clinical explanations permits detailed classification of explanation types and content. Explanation types appear to carry different implications of agency. PRACTICE IMPLICATIONS The taxonomy is suitable for examining explanations and developing prototype explanatory scripts in both training and research settings.
Collapse
Affiliation(s)
- LaKrista Morton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Alison Elliott
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Jennifer Cleland
- Division of Medical and Dental Education, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Vincent Deary
- Department of Psychology, Northumbria University, Newcastle-upon-Tyne, NE1 8ST, UK.
| | - Christopher Burton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| |
Collapse
|
89
|
den Boeft M, Huisman D, Morton L, Lucassen P, van der Wouden JC, Westerman MJ, van der Horst HE, Burton CD. Negotiating explanations: doctor-patient communication with patients with medically unexplained symptoms-a qualitative analysis. Fam Pract 2017; 34:107-113. [PMID: 28122926 DOI: 10.1093/fampra/cmw113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients with medically unexplained physical symptoms (MUPS) seek explanations for their symptoms, but often find general practitioners (GPs) unable to deliver these. Different methods of explaining MUPS have been proposed. Little is known about how communication evolves around these explanations. OBJECTIVE To examine the dialogue between GPs and patients related to explanations in a community-based clinic for MUPS. We categorized dialogue types and dialogue outcomes. METHODS Patients were ≥18 years with inclusion criteria for moderate MUPS: ≥2 referrals to specialists, ≥1 functional syndrome/symptoms, ≥10 on the Patient Health Questionnaire-15 and GP's judgement that symptoms were unexplained. We analysed transcripts of 112 audio-recorded consultations (39 patients and 5 GPs) from two studies on the Symptoms Clinic Intervention, a consultation intervention for MUPS in primary care. We used constant comparative analysis to code and classify dialogue types and outcomes. RESULTS We extracted 115 explanation sequences. We identified four dialogue types, differing in the extent to which the GP or patient controlled the dialogue. We categorized eight outcomes of the sequences, ranging from acceptance to rejection by the patient. The most common outcome was holding (conversation suspended in an unresolved state), followed by acceptance. Few explanations were rejected by the patient. Co-created explanations by patient and GP were most likely to be accepted. CONCLUSION We developed a classification of dialogue types and outcomes in relation to explanations offered by GPs for MUPS patients. While it requires further validation, it provides a framework, which can be used for teaching, evaluation of practice and research.
Collapse
Affiliation(s)
- Madelon den Boeft
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands,
| | - Daniëlle Huisman
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - LaKrista Morton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands and
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Marjan J Westerman
- Department of Methodology and Statistics, Institute of Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Christopher D Burton
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| |
Collapse
|
90
|
Symptoms and the body: Taking the inferential leap. Neurosci Biobehav Rev 2017; 74:185-203. [PMID: 28108416 DOI: 10.1016/j.neubiorev.2017.01.015] [Citation(s) in RCA: 296] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/01/2016] [Accepted: 01/11/2017] [Indexed: 12/19/2022]
Abstract
The relationship between the conscious experience of physical symptoms and indicators of objective physiological dysfunction is highly variable and depends on characteristics of the person, the context and their interaction. This relationship often breaks down entirely in the case of "medically unexplained" or functional somatic symptoms, violating the basic assumption in medicine that physical symptoms have physiological causes. In this paper, we describe the prevailing theoretical approach to this problem and review the evidence pertaining to it. We then use the framework of predictive coding to propose a new and more comprehensive model of the body-symptom relationship that integrates existing concepts within a unifying framework that addresses many of the shortcomings of current theory. We describe the conditions under which a close correspondence between the experience of symptoms and objective physiology might be expected, and when they are likely to diverge. We conclude by exploring some theoretical and clinical implications of this new account.
Collapse
|
91
|
Karatzias T, Howard R, Power K, Socherel F, Heath C, Livingstone A. Organic vs. functional neurological disorders: The role of childhood psychological trauma. CHILD ABUSE & NEGLECT 2017; 63:1-6. [PMID: 27886517 DOI: 10.1016/j.chiabu.2016.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 06/06/2023]
Abstract
Although the relationship between psychological trauma and medically unexplained symptoms (MUS) is well established, this relationship is less well understood in people with medically unexplained neurological symptoms. In the present study, we set out to compare people with functional neurological disorders, and organic neurological disorders, in terms of childhood and adulthood traumatic events, traumatic stress, emotional dysregulation and symptoms of depression and anxiety. We have hypothesised that those with functional neurological disorders would be more likely to report childhood and adulthood traumatic life events, traumatic symptomatology, emotional dysregulation and symptoms of anxiety and depression, compared to those with organic neurological disorders. Sample consisted of a consecutive series of people with functional neurological disorders and with organic neurological disorders (n=82) recruited from a hospital in Scotland. Participants completed measures of life events, traumatic stress, emotional regulation, anxiety and depression. The two groups were found to significantly differ in relation to all measures, with the MUS group being more likely to report childhood and adulthood life events, more severe emotional dysregulation, traumatic stress and symptoms of anxiety and stress. Logistic regression analysis revealed that exposure to childhood traumatic life events, specifically childhood sexual abuse, and childhood physical neglect, were the only factors which were significantly associated with membership of the medically unexplained neurological symptoms group. Although further research is required to confirm our findings, our results suggest that identifying and addressing the impact of childhood trauma, may alleviate distress and aid recovery from functional neurological disorders.
Collapse
Affiliation(s)
- Thanos Karatzias
- Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK; NHS Lothian, Rivers Centre for Traumatic Stress, Edinburgh, UK.
| | - Ruth Howard
- Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
| | - Kevin Power
- NHS Tayside, Psychological Therapies Service, Dundee, UK; University of Stirling, School Of Natural Sciences, Stirling, UK
| | | | - Craig Heath
- Department of Neurology, Institute of Neurological Sciences, Glasgow, UK
| | | |
Collapse
|
92
|
Cooper S, Gilbert L. An exploratory study of the experience of fibromyalgia diagnosis in South Africa. Health (London) 2016; 21:337-353. [PMID: 28521648 DOI: 10.1177/1363459316677623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Within the conceptual framework of 'medically-ill-defined' conditions, this article focuses on the experiences of 'diagnosis' through a narrative analysis of fibromyalgia (a chronic musculoskeletal pain disorder) in South Africa. In-depth interviews were used to collect narratives from 15 participants. The findings show how the contested and confusing experience of fibromyalgia diagnosis can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The currency of fibromyalgia as a diagnosis and the inequalities present in the South African health care system characterise the experiences of symptom recognition, diagnosis and treatment. The analysis reveals how those living with fibromyalgia search for diagnosis, and struggle to maintain legitimacy for their experience in the complex constellation of porous symptoms that appear infrequently. The findings of this study confirm the existing evidence that shows fibromyalgia to be a challenging illness experience, which is attributed to the lack of clarity and legitimacy, and high contestation that surrounds the condition. Additionally, this study presents the ways that limited access to diagnosis and treatment for fibromyalgia in the South African context shapes this specific illness experience, and the value of using narrative approaches to gain insight into how people live with hidden and poorly understood conditions in this environment.
Collapse
Affiliation(s)
- Silvie Cooper
- University of the Witwatersrand, Johannesburg, South Africa
| | - Leah Gilbert
- University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
93
|
Open Trial of Integrated Primary Care Consultation for Medically Unexplained Symptoms. J Behav Health Serv Res 2016; 44:590-601. [PMID: 27530260 DOI: 10.1007/s11414-016-9528-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Within primary care settings, patients with medically unexplained symptoms (MUS) are common, often present with comorbid psychopathology, and have high rates of healthcare utilization. Despite increased healthcare utilization, these patients often have poor outcomes that frustrate patients and providers alike. A behavioral consultation intervention for primary care patients with MUS (n = 10) was developed and assessed. All participants completed all intervention and assessment sessions and rated the intervention favorably. Participants self-report scores revealed statistically significant improvements from baseline to 3-month follow-up on physical functioning, mental functioning, and physical symptoms. Notwithstanding the limitations of open trial designs, these findings demonstrate high feasibility for a behavioral health consultation treatment model for patients with MUS and highlight the need for further research.
Collapse
|
94
|
Andreasson A, Wicksell RK, Lodin K, Karshikoff B, Axelsson J, Lekander M. A global measure of sickness behaviour: Development of the Sickness Questionnaire. J Health Psychol 2016; 23:1452-1463. [PMID: 27458105 DOI: 10.1177/1359105316659917] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Symptoms after inflammatory activation, so-called sickness behaviour, overlap with trans-diagnostic complaints. As no self-report questionnaire to assess sickness behaviour exists, we aimed to develop such an instrument, the Sickness Questionnaire. Items responsive to experimentally induced inflammatory activation (randomized double-blind study endotoxin (0.6 ng/kg) versus placebo, n = 52) were selected and the statistical properties were examined in 172 primary care patients. A principal component analysis indicated a one-factor solution (Cronbach's alpha = .86). This 10-item scale correlated with depression ( β = .41, p < .001), anxiety ( β = .36, p < .001), self-rated health ( β = .28, p < .001) and a single item of feeling sick ( β = .55, p < .001). The results support the adequacy of Sickness Questionnaire as a brief assessment instrument of perceived sickness behaviour.
Collapse
Affiliation(s)
- Anna Andreasson
- 1 Karolinska Institutet, Sweden.,2 Stockholm University, Sweden
| | - Rikard K Wicksell
- 1 Karolinska Institutet, Sweden.,3 Karolinska University Hospital, Sweden
| | | | | | - John Axelsson
- 1 Karolinska Institutet, Sweden.,2 Stockholm University, Sweden
| | - Mats Lekander
- 1 Karolinska Institutet, Sweden.,2 Stockholm University, Sweden
| |
Collapse
|
95
|
McWilliams A, Reilly C, McFarlane FA, Booker E, Heyman I. Nonepileptic seizures in the pediatric population: A qualitative study of patient and family experiences. Epilepsy Behav 2016; 59:128-36. [PMID: 27131915 DOI: 10.1016/j.yebeh.2016.03.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/10/2016] [Accepted: 03/20/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to characterize the experience of nonepileptic seizures (NES) in young people (0-19years) and their families, referred to a UK specialist (tertiary) pediatric hospital. The topics investigated include: accessing healthcare, how the diagnosis was first explained, impact on home life and school, coping strategies, and ideas about naming and causes. METHODS Ten young people with NES and 29 family members took part in focus groups and telephone interviews. The data generated were analyzed qualitatively with thematic analysis. RESULTS Six themes were identified from participant experiences: upset and afraid, missing out, feeling misunderstood, confusion and uncertainty, less than epilepsy, and making sense and moving on. Participants described severe disruption to multiple domains of functioning at home, educationally, and in social activities. Young people felt guilty but also overprotected, while family members felt that they were failing as parents. The journey to diagnosis and treatment was seen as unnecessarily tortuous, with access to care and treatment pathways poorly defined. Participants described feeling that a wide variety of professionals did not believe their experiences, showed pejorative attitudes, and left them feeling isolated and marginalized. The young people and family members found NES a difficult disorder to understand and sometimes could not differentiate it from epilepsy. Epilepsy was used as a benchmark for several comparisons, including highlighting the lack of support for and information about NES. Families disliked being told that it was "good news" that their child did not have epilepsy and questioned if their child should be present during initial diagnostic discussions. Participants described stressful situations as a common trigger for NES. Young people showed ambivalence towards the need to understand the condition or the choice of name used for it, whereas family members considered this crucial for achieving recovery. CONCLUSIONS Young people and families who live with NES experience considerable distress and impairment. Pathways to diagnosis need to be streamlined, and better integration of pediatric, mental health, and educational services is required. The use of the "good news" story to discuss the diagnosis with families should be reconsidered, as families seem to interpret this as indicating that there is no effective treatment. Educational resources and support groups for young people and families are needed. Greater understanding of experiences may allow investigation of the pathogenic mechanism and inform possible management approaches. Training of health professionals in communicating with young people and families with NES must be improved.
Collapse
Affiliation(s)
- Andrew McWilliams
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK; UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK; Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Garrod Building, Turner St, London, E1 2AD, UK.
| | - Colin Reilly
- Research Department, Young Epilepsy, Lingfield, Surrey RH7 6PW, UK; Gillberg Neuropsychiatry Centre, University of Gothenburg, Kungsgatan 12, Gothenburg, Sweden
| | - Fiona A McFarlane
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK; UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK
| | - Emily Booker
- UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK
| | - Isobel Heyman
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK; UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK
| |
Collapse
|
96
|
Menon V, Sarkar S, Thomas S. Establishing a psychosomatic clinic in a low resource setting: Process, challenges, and opportunities. J Neurosci Rural Pract 2016; 7:171-5. [PMID: 26933373 PMCID: PMC4750324 DOI: 10.4103/0976-3147.172157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Specialty psychosomatic clinics are a felt need in low- and middle-income countries, but its benefits and challenges have not been reported so far. AIMS To describe the process, challenges, and opportunities that we encountered in setting up a specialty psychosomatic clinic at a government medical college in South India. METHODS The biweekly psychosomatic clinic was located in the Department of Psychiatry and manned by a multimodal team. Structured questionnaires were used to evaluate all patients. All psychiatric diagnoses were made as per International Classification of Diseases-10, clinical descriptions and diagnostic guidelines. Management comprised both pharmacotherapy and psychotherapeutic interventions. RESULTS A total of 72 patients registered for services in the 1(st) year of the clinic. The mean age of the sample was 36.6 years (range 14-60 years). A median of 2 years and 19 visits to various care providers had elapsed before their visit to the clinic. The index contact was a general practitioner in the majority of cases though an overwhelming majority (95.6%) had also sought specialist care. The most common diagnostic cluster was the somatoform group of disorders (50.0%). Antidepressants were the most commonly prescribed medications (70.6%). CONCLUSION The specialty psychosomatic clinic provided better opportunities for a more comprehensive evaluation of people with medically unexplained symptoms and better resident training and focused inter-disciplinary research. It describes a scalable model that can be replicated in similar resource constrained settings.
Collapse
Affiliation(s)
- Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Siddharth Sarkar
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
| | - Shijo Thomas
- Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| |
Collapse
|
97
|
Hubley S, Uebelacker L, Eaton C. Managing Medically Unexplained Symptoms in Primary Care: A Narrative Review and Treatment Recommendations. Am J Lifestyle Med 2016; 10:109-119. [PMID: 30202265 PMCID: PMC6125096 DOI: 10.1177/1559827614536865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/17/2014] [Accepted: 03/07/2014] [Indexed: 11/17/2022] Open
Abstract
Medically unexplained symptoms (MUS) are persistent physical symptoms in the absence of identifiable disease. MUS present a major challenge for primary care providers (PCPs) because complex symptom presentations, strained patient-physician relationships, and treatment-resistant symptoms can challenge a PCP's sense of competency. This review is intended to help PCPs understand the burden and theoretical context of MUS and to provide concise recommendations for managing MUS within primary care settings. Based on a narrative review of the literature, these recommendations emphasize in particular the importance of co-creating plausible explanations for MUS, understanding the pitfalls of consultations involving MUS, and developing multimodal treatment plans.
Collapse
Affiliation(s)
- Sam Hubley
- Alpert Medical School of Brown University, Center for Primary Care and Prevention, Memorial Hospital of Rhode Island and Brown University, Pawtucket, Rhode Island
| | - Lisa Uebelacker
- Alpert Medical School of Brown University, Center for Primary Care and Prevention, Memorial Hospital of Rhode Island and Brown University, Pawtucket, Rhode Island
| | - Charles Eaton
- Alpert Medical School of Brown University, Center for Primary Care and Prevention, Memorial Hospital of Rhode Island and Brown University, Pawtucket, Rhode Island
| |
Collapse
|
98
|
Young K, Fisher J, Kirkman M. Endometriosis and fertility: women's accounts of healthcare. Hum Reprod 2016; 31:554-62. [PMID: 26759140 DOI: 10.1093/humrep/dev337] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/15/2015] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What do women with endometriosis recall being told about their fertility by their healthcare providers? SUMMARY ANSWER Women recalled being given varied information and advice, and gave examples of empathic and individualized care from doctors but also reported opportunities for enhancing clinical practice. WHAT IS KNOWN ALREADY There is evidence of an association between endometriosis and infertility. However, the strength of this association and the mechanisms that underlie it are not yet known nor are the implications for optimum healthcare. STUDY DESIGN, SIZE, DURATION This study used in-depth cross-sectional qualitative research methods. PARTICIPANTS/MATERIALS, SETTING, METHODS Women aged at least 18 years who lived in Victoria, Australia, and who had been surgically diagnosed with endometriosis were invited to participate in in-depth interviews about their experience of endometriosis. Twenty-six women of diverse backgrounds and experiences of endometriosis were interviewed from January to September 2014. Interviews were transcribed and analysed thematically using a data-driven approach. MAIN RESULTS AND THE ROLE OF CHANCE All women encountered medical professionals who were aware of the association between endometriosis and infertility, and who were proactive in ensuring fertility was addressed within endometriosis care. Women recalled being given varied, often conflicting, information about the consequences for their fertility of an endometriosis diagnosis. While some recounted positive experiences with the way their doctor communicated with them about endometriosis and fertility, all women reported adverse experiences such as receiving insufficient or inappropriate information or having their doctor prioritize their fertility over other aspects of their care, including quality of life and symptom relief, without first consulting them. LIMITATIONS, REASONS FOR CAUTION The perspectives of the women's doctors were not sought. The findings may not translate to settings that differ from a predominantly Anglo-Saxon country with both universal public and private healthcare systems. WIDER IMPLICATIONS OF THE FINDINGS Women's fertility needs and priorities differ for many reasons; there can be no 'one size fits all' approach to care. Women may benefit most from endometriosis care in which they are first asked about their fertility needs and preferences and in which medical uncertainty is acknowledged. STUDY FUNDING/COMPETING INTERESTS K.Y. receives a scholarship from the National Health and Medical Research Council and Australian Rotary Health. J.F. is supported by a Monash Professional Fellowship and the Jean Hailes Professional Fellowship which is funded by Perpetual Trustees Pty Ltd. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER Not applicable.
Collapse
Affiliation(s)
- K Young
- The Jean Hailes Research Unit, Monash University, 1st Floor, 549 St Kilda Rd, Melbourne, Victoria 3004, Australia
| | - J Fisher
- The Jean Hailes Research Unit, Monash University, 1st Floor, 549 St Kilda Rd, Melbourne, Victoria 3004, Australia
| | - M Kirkman
- The Jean Hailes Research Unit, Monash University, 1st Floor, 549 St Kilda Rd, Melbourne, Victoria 3004, Australia
| |
Collapse
|
99
|
Novick D, Montgomery WS, Aguado J, Peng X, Brugnoli R, Haro JM. Which somatic symptoms are associated with an unfavorable course in Chinese patients with major depressive disorder? Asia Pac Psychiatry 2015; 7:427-35. [PMID: 26047023 DOI: 10.1111/appy.12189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 04/21/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION This was an analysis of the impact of somatic symptoms on the severity and course of depression in Chinese patients treated for an acute episode of major depressive disorder (MDD). METHODS Data were extracted from a 3-month prospective observational study which enrolled 909 patients with MDD in psychiatric care settings; this analysis focused on the Chinese patients (n=300). Depression severity was assessed using the Clinical Global Impression of Severity (CGI-S) and 17-item Hamilton Depression Rating Scale (HAMD-17); somatic symptoms were assessed using the patient-rated 28-item Somatic Symptom Inventory (SSI). Cluster analysis using baseline SSI scores grouped patients into three clusters with no/mild, moderate, or severe somatic symptoms. Four SSI factors (pain, autonomic symptoms, energy, and central nervous system) were defined, and regression analyses identified which factors were associated with remission at 3 months. RESULTS More than 70% of the patients had moderate or severe somatic symptoms. Baseline depression severity (HAMD-17 and CGI-S scores) was associated with more severe somatic symptoms. Remission rates differed between clusters of patients: 84.1%, 72.0%, and 55.3% for no/mild, moderate, and severe somatic symptoms, respectively (P=0.0034). Pain symptoms were the somatic symptoms more strongly associated with lower remission rates at 3 months. DISCUSSION Somatic symptoms are associated with greater clinical severity and lower remission rates. Among somatic symptoms, pain symptoms have the greatest prognostic value and should be taken into account when treating patients with depression.
Collapse
Affiliation(s)
| | | | - Jaume Aguado
- Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Barcelona, Spain
| | | | | | - Josep Maria Haro
- Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
100
|
Moukaddam N, AufderHeide E, Flores A, Tucci V. Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department. Emerg Med Clin North Am 2015; 33:797-810. [PMID: 26493524 DOI: 10.1016/j.emc.2015.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.
Collapse
Affiliation(s)
- Nidal Moukaddam
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA.
| | - Erin AufderHeide
- Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, USA
| | - Araceli Flores
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA
| | - Veronica Tucci
- Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, USA
| |
Collapse
|