Longing for existential recognition: a qualitative study of everyday concerns for people with somatoform disorders

Changes in Patient Discourse: A Qualitative Study Based on the Treatment Experience of Chinese Patients with Somatization Symptoms

This qualitative study examines the characteristics exhibited by Chinese patients with somatization symptoms during their treatment process, focusing on changes in illness interpretation and language use. A semi-structured in-depth interview was conducted with 10 patients receiving treatment in a clinical psychology department of a general hospital who reported somatic symptoms as their main complaint. The interview data were recorded and transcribed, and analyzed using interpretive phenomenological analysis. Two core themes emerged from the analysis: avoidance at the utterance level; and at the semantic level, power and contestation. Patients with somatization symptoms exhibit avoidance behaviors, and their experience of illness and the therapeutic process impact their discourse. Professionals should pay attention to patients' own interpretations, cultural background and acceptance of the illness.

Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners

BACKGROUND

When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides.

OBJECTIVES

To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful.

METHODS

Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation.

RESULTS

Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function.

CONCLUSIONS

Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.

Management of uncertainty in the diagnosis communication of psychogenic nonepileptic seizures in a South African context

The process of communicating a diagnosis of psychogenic nonepileptic seizures (PNES) is an integral part of the treatment process. Many international studies have therefore focused on the PNES diagnosis communication process, but to date, none with a specific focus on the South African context. This current study considered the factors that influence the patient's experience of uncertainty and the strategies employed to manage that uncertainty within the provider-patient communication. This was considered from the healthcare provider's point of view, within the specific context of diagnosis communication. We conducted 13 semi-structured interviews with providers, eliciting their perceptions related to the communication of a PNES diagnosis to patients. Data were analyzed using thematic analysis, and themes were grouped according to the main tenets of the interpersonal health communication theory of uncertainty management, which included, the experience, appraisal, and management of uncertainty. The results revealed medical, personal, and social forms of uncertainty. The social sources of uncertainty, which include challenges related to the South African healthcare system, cultural, and language variability within the South African context, as well as possible stigmatization, seemed to have the biggest influence not only on the other areas of uncertainty, but was also indicated as a barrier to effective uncertainty management by providers. Providers in this study identified the importance of building the provider-patient relationship and ensuring patient understanding, as the main strategies used to reduce uncertainty. There was some evidence to suggest varied emotional appraisals of uncertainty by patients, but because of the subjective nature of this information, further research would be needed to confirm these findings. These findings suggest that as providers, one cannot apply a one-size-fits-all approach when aiding in uncertainty management. Furthermore, it is pertinent to remain cognizant of the social realities of the South African context and its impact on the patient's uncertainty experience. More research is needed to understand patients' perceptions of uncertainty management within the context of PNES diagnosis communication, and how they align with the perceptions of the providers provided here.

Overcoming Clinician and Parent Ambivalence: General Practitioners' Support of Children of Parents With Physical or Mental Illness and/or Substance Abuse

Children who are next of kin to parents with physical or mental illness and/or substance abuse need access to mental health support and several cost-effective interventions are available. Because most parents in the target group often consult general practitioners (GPs), GPs may have a crucial role in identifying burdened children and ensuring their follow-up. However, this important topic has received little attention in clinical discussions and research. In response to the knowledge gap, we conducted the research project Burdened Children as Next of Kin and the General Practitioner. Four sub-studies have been completed and published: a sub-study with qualitative analysis of focus group interviews with GPs (paper 1), a qualitative analysis of focus group interviews with adolescents as next of kin (paper 2), and a qualitative analysis of individual interviews with parents with illness and/or substance abuse (paper 3). The results from these sub-studies were incorporated in a survey sent to members of a nationwide GP organization (paper 4). The aim of the present sub-study was to gain further knowledge about conditions for the encounters between GPs and parents with impairments to be supportive for the children as next of kin. The material of the present sub-study derived from the project's four previous sub-studies and comprised a secondary analysis of the four prior sub-studies. We conducted an overarching thematic analysis of these sub-studies' results sections. We searched for statements from the GPs, the adolescents, and the parents on their experiences and evaluations of the needs of the children and their families, and the possible ways of accommodating these needs in general practice. The analysis shows that both GPs and parents were ambivalent about addressing the topic of the patients' children during consultations. This was the case although the GPs were in a good position to identify these vulnerable children, and the parents were worried about their children's situations. Possible strategies for GPs to overcome this ambivalence can be to (1) strengthen their competence in the topic, (2) gradually build trusting relationships with parents, and (3) gradually gain contextual knowledge about the families' situations. GPs can do this by performing ordinary GP tasks and acknowledging the parents' efforts to give their children good daily lives.

Patients' experiences and care needs during the diagnostic phase of an integrated brain cancer pathway: A case study

AIMS AND OBJECTIVES

To identify and describe patients' experiences and care needs throughout the diagnostic phase of an integrated brain cancer pathway.

BACKGROUND

A malignant brain tumour is a devastating diagnosis, which may cause psychical symptoms and cognitive deficits. Studies have shown that the shock of the diagnosis, combined with the multiple symptoms, affects patients' ability to understand information and express needs of care and support. Unmet needs have been reported within this group of patients; however, the experiences and care needs of patients going through the diagnostic phase of a standardised integrated brain cancer pathway have not previously been explored.

DESIGN

A case study design was used to provide detailed information of the complex needs of patients being diagnosed with a malignant brain tumour.

METHODS

Research interviews and direct participant observation of four patients during hospital admission, brain surgery and discharge were conducted in a Danish university hospital. Systematic text condensation was used to analyse the data material.

RESULTS

Four major themes were identified: information needs, balancing hope and reality while trying to perceive the unknown reality of brain cancer, not knowing what to expect and participants' perceptions of the relationship with the healthcare providers. The analysis revealed that participants were in risk of having unmet information needs and that contextual factors seemed to cause fragmented care that led to feelings of uncertainty and loss of control.

CONCLUSIONS

Brain tumour patients have complex care needs and experience a particular state of vulnerability during the diagnostic phase. Through personal relationships based on trust with skilled healthcare providers, participants experienced an existential recognition and alleviation of emotional distress.

RELEVANCE TO CLINICAL PRACTICE

Patients receiving a brain tumour diagnosis experience unmet care needs in several areas during their hospital stay. There is a need for interventions from healthcare providers.

Personalized treatment outcomes in patients with somatoform disorder: A concept mapping study

OBJECTIVE

From a patient-centered perspective, treatment outcome measures in somatoform disorder need to be (1) personalized to the patient, (2) fit core problems that are targeted in therapy, and (3) reflect one's ability to adapt and self-manage anticipated deterioration. The aim of this study was to identify an encompassing set of treatment outcome variables in patients with somatoform disorder.

METHODS

In-depth interviews yielded a comprehensive overview of 60 treatment outcomes that were sorted in a card sorting task according to similarity of meaning by 30 patients. Hierarchical cluster analysis (squared Euclidean distances, Ward's method) was used to obtain a structured overview of treatment outcomes unbiased by subjective interpretations of researchers. Perceived importance and personal change were examined using descriptive statistics.

RESULTS

The hierarchical structure of treatment outcomes showed seven clusters, classified in two broad categories: self-other relationships (comprising social support, health care use, and self-confidence) and self-management (comprising physical balance, psychological adjustment, symptom acceptance, and resilience). Ratings of the importance of the clusters showed large individual differences. Most participants retrospectively perceived positive personal change.

CONCLUSION

The wide variety of treatment outcomes and the observation that patients attach different importance to the outcome measures supports the value of developing new personalized outcome measures for effect studies. In clinical practice, the clusters of outcomes can be used in shared decision making during intake, to define treatment goals, and to map and evaluate change on a personalized set of outcome measures.

Disabled and elderly citizens' perceptions and experiences of voluntarism as an alternative to publically financed care in the Netherlands

Many European welfare states are replacing comprehensive welfare schemes with selective and conditional entitlements. Such changes affect the recognition of vulnerable citizens' needs, which are increasingly framed as private responsibilities to be met by the voluntary sector. Repeated interviews with 30 clients affected by cutbacks to publicly financed (day)care in the Netherlands show that although disabled and elderly citizens are often hesitant to open their doors to volunteers, they do experiment with voluntarism to reduce their social isolation, both by receiving voluntary care and by engaging in volunteer work themselves. However, the turn to voluntarism does not always prompt recognition of the needs of vulnerable citizens. This study signals how disappointing and sometimes demeaning experiences with volunteers can increase feeling of misrecognition. We conclude that the virtues of voluntarism may be overstated by policy makers and that the bases of recognition should be reconsidered as welfare states implement reform.

Coping with psychosomatic symptoms: The buffering role of psychological flexibility and impact on quality of life

Individual differences in avoidant coping were hypothesized to exacerbate quality of life impairment associated with somatization and illness anxiety symptoms; psychological flexibility was expected to moderate this impairment. Individuals from a random community sample ( N = 298; 182 females), who met screening criteria for somatization and illness anxiety, reported lower quality of life and psychological flexibility and greater avoidant coping compared to controls. Psychological flexibility significantly moderated the impact of somatization and illness anxiety on quality of life domains. Findings suggest that decreasing avoidant coping through therapy may be promising in mitigating the negative impact of these symptom categories.

Life after being diagnosed with psychogenic non-epileptic seizures (PNES): a South African perspective

PURPOSE

The aim of the study was to explore the life experiences of South Africans who have been diagnosed as having PNES, with a focus on the aspects of the challenges which these individuals face, as well as the resources and coping strategies which are either made available to them or used by them in order to cope with PNES.

METHODS

Ten semi-structured interviews were analysed by means of thematic analysis in order to explore themes around challenges and resources for those diagnosed with PNES.

RESULTS

Various challenges were revealed by participants, as well as the resources used in order to deal with these challenges associated with being diagnosed with PNES. Some of the challenges included unexpected seizures, medical professionals, belief systems as well as family. However, resources to counteract these challenges were social support, medical professional as well as religion and spirituality.

CONCLUSION

Although many challenges are encountered by those who are diagnosed with PNES, there are substantial resources from which these individuals draw in order to live fulfilling and satisfactory lives. As more information and research is accumulated, more resources may become available to benefit these individuals and allow them to recover from PNES. It should be noted that medical professionals were described as both a challenge as well as a resource for people with PNES. Therefore, we can conclude that these individuals are key in the experiences of those who have been diagnosed with PNES, and that they play a role on not only a diagnostic level, but also in providing support, information, as well as therapeutic benefits.

Assessing the affective load in the narratives of women suffering from fibromyalgia: the clinicians' appraisal

OBJECTIVE

Fibromyalgia is characterized by chronic widespread pain and various associated symptoms, including psychological distress. This study presents a secondary analysis of the interviews of patients with fibromyalgia to appraise the affective load of the patient narratives as assessed by independent clinicians.

SETTING AND PARTICIPANTS

Three clinicians, an internist, a psychiatrist and a psychologist, who were experienced in chronic pain reviewed the interview transcripts of 56 women eliciting their views regarding fibromyalgia onset. A Clinical Global Impression (CGI) scale was used (0 = no affective load to 5 = maximum affective load) to provide a subjective appraisal of the intensity of the affective impact, as suggested in the transcripts and from the clinician perspectives.

RESULTS

The mean affective load was 3.6 (SD = ±1), indicating the perception of a high affective load in the clinicians. Values indicating a high or very high affective load (≥4 points on the CGI scale) were more frequent than those in the lower range [23 narratives (41%) vs. 3 (5%)]. The inter-rater agreement of the affective load of the narratives was high (K > 0.85). These results of the clinician perspectives parallel those of the patient narratives, emphasizing disruptive circumstances, psychological distress and hopelessness surrounding symptom onset.

CONCLUSION

The affective load in the narratives of these patients with fibromyalgia was high and had a negative undertone when considered from the clinicians' perspective. This study highlights the importance of considering the affective resonance in the context of therapeutic relationships that are often emotionally laden and highly challenging for the clinician.

Searching for existential security: a prospective qualitative study on the influence of mindfulness therapy on experienced stress and coping strategies among patients with somatoform disorders

OBJECTIVE

The aim was to explore how mindfulness group therapy for somatoform disorders influenced the patients' stress experiences, coping strategies and contextual psychosocial processes.

METHODS

A longitudinal pre- and post-treatment design, using 22 semi-structured individual pre- and post-treatment interviews. Data-analysis was based on a thematic methodology.

RESULTS

Pre-treatment patients were struggling in an existential crisis, feeling existentially insecure about their social identity, the causes, consequences and management of their illness; experiencing difficulties identifying and expressing stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact; often leading to avoidant coping, making these individuals highly stress-vulnerable. Post-treatment, the overall change was conceptualized as increased existential security, defined by patients being more self-confident; more clarified with their social identity, the nature, management and future prospects of their illness; generally using more flexible coping strategies to reduce their daily stress experiences. Four related subthemes were identified contributing to increased existential security: 1) more secure illness perceptions - feeling existentially recognized as "really" ill, 2) enhanced relaxation ability - using mindfulness techniques, 3) increased awareness - connecting differently to mind and body 4) improved ability to identify and express needs and feelings of distress - more active communicating. Patients suggested that mindfulness therapy could be expanded with more time for group-discussions followed by additional individual therapy.

CONCLUSION

Generally, treatment positively influenced the patients' illness perceptions, stress-experiences, body- and self-awareness, coping strategies, self-image, social identity and social functioning. However, patients identified potentials for treatment improvements, and they needed further treatment to fully recover.

Struggling in an emotional avoidance culture: a qualitative study of stress as a predisposing factor for somatoform disorders

OBJECTIVE

To explore patterns of experienced stress and stress reactions before the onset of illness in the life history of patients with severe somatoform disorders to identify predisposing stress-mechanisms.

METHODS

A systematic, thematic analysis was conducted on data collected from 24 semi-structured individual life history interviews.

RESULTS

Generally, patients had experienced high psychosocial stress during childhood/youth. However, there was considerable variability. Characteristic of all patients were narrations of how communication with significant adults about problems, concerns, and emotions related to stress were experienced to be difficult. The patients described how this involved conflicts stemming from perceived absent, insufficient, or dismissive communication during interactions with significant adults. We conceptualized this empirically based core theme as "emotional avoidance culture." Further, three related subthemes were identified: Generally, patients 1.) experienced difficulties communicating problems, concerns, and related complex feelings in close social relations; 2.) adapted their emotional reactions and communication to an emotional avoidance culture, suppressing their needs, vulnerability and feelings of sadness and anger that were not recognized by significant adults; and 3.) disconnected their stress reaction awareness from stressful bodily sensations by using avoidant behaviors e.g. by being highly active.

CONCLUSION

Patients adapted to an emotional avoidance culture characterized by difficult and conflicting communication of concerns and related emotions in social interactions with significant adults. Patients experienced low ability to identify and express stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact, which made them vulnerable to stressors. Generally, patients resolved stress by avoidant behaviors, prolonging their stress experience.