Towards a sociology of diagnosis: Reflections and opportunities

Internet-Delivered Psychoeducation (SCOPE) for Transition-Aged Autistic Youth: Pragmatic Randomized Controlled Trial

BACKGROUND

Psychoeducation is a recommended first-line intervention for transition-aged autistic youth, but it has not been previously evaluated in an internet-delivered format. SCOPE (Spectrum Computerized Psychoeducation) is an 8-week individual, internet-delivered, therapist-supported psychoeducative intervention.

OBJECTIVE

This study aimed to investigate the effectiveness of SCOPE through a 3-armed randomized controlled trial. The intervention aims to increase participants' understanding of autism and, in doing so, increase their quality of life (QoL).

METHODS

SCOPE was codeveloped with clinicians and autistic young adults. It contains 8 autism-related modules, each with (1) text describing the module topic, (2) four video vignettes with recurring characters who describe their lives and perspectives on the module topic, (3) a list of neurotypical characteristics related to the module's topic, and (4) self-reflection using 3 or 4 questions about the module topic, answered by multiple-choice bullets and voluntary open-ended written comments. Participants were randomized (2:1:1) to SCOPE, an active control (web-based self-study), or treatment as usual (TAU). The primary outcome was participants' autism knowledge, assessed using the Autism Spectrum Disorder Quiz, and secondary outcomes included acceptance of diagnosis, QoL, and symptoms of mental health problems. All outcomes were assessed at the baseline, postintervention, and 3-month follow-up time points, using mixed-effects models to assess change in outcome measures across time points.

RESULTS

Between 2014 and 2020, a total of 141 participants were randomized to 1 of the 3 treatment arms. The SCOPE participants had significantly greater autism knowledge gains at the posttreatment time point compared to TAU participants with a moderate effect size (d=0.47; P=.05); gains were maintained at the 3-month follow-up (d=0.46; P=.05). The self-study participants also had increased knowledge gains compared to TAU participants at the posttreatment time point with a moderate effect size (d=0.60; P=.03) but did not maintain these gains at the 3-month follow-up, and their autism knowledge scores returned to baseline (mean change score: -0.13, 95% CI -1.20 to 0.94; P=.81). In addition, SCOPE participants reported improved QoL at the postintervention (d=0.37, P=.02) and 3-month follow-up time points (d=0.60; P=.001), compared to the combined controls. The gained autism knowledge was not mirrored by changes in symptoms of anxiety or depression.

CONCLUSIONS

Effective internet-delivered interventions may facilitate first-line service access to individuals who are unable or unwilling to use traditional health care interventions or who live in geographically remote locations. Additionally, an intervention such as SCOPE could impart and sustain the knowledge gained through psychoeducation in transition-aged autistic youth. For future research, qualitative studies could further our understanding of the lived experiences of intervention participation and outcomes after internet-delivered psychoeducation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03665363; https://clinicaltrials.gov/study/NCT03665363.

Understanding diagnostic delays and health outcomes for inflammatory bowel disease: a mixed-methods study of patients' perspectives

PURPOSE

Inflammatory bowel disease (IBD) is a chronic condition affecting the digestive system with symptoms that are often episodic, unpredictable, socially stigmatizing, and impact quality of life. While a timely diagnosis reduces the risk of complications and improves health outcomes, diagnostic delays (DDs) are common. Our study used narratives and data from patient-reported outcome measures (PROMs) of individuals diagnosed with IBD to examine: (1) What factors helped or hindered achieving a timely diagnosis of IBD? and (2) how do DDs relate to PROMs?

METHODS

We conducted a mixed-methods study of 296 individuals diagnosed with IBD in Canada. The survey included a set of validated measures that assessed depression, fatigue, satisfaction with life, disease severity, and several open-ended questions.

RESULTS

Thematic analysis of open-ended responses revealed five themes that highlighted the ways a diagnosis was delayed or facilitated: symptom ambiguity, fear and denial, patient-provider communication breakdown, misdiagnosis and self-doubt, and self-advocacy. Quantitative findings revealed that a longer time to receive a diagnosis was significantly correlated with higher levels of depression (r = .26) and fatigue (r = .25), reduced satisfaction with life (r =  - .25), and greater disease severity (r =  - .22). We used the data to generate a framework called the Diagnostic Pathways Model to illustrate the diagnostic process of a chronic disease such as IBD.

CONCLUSION

DDs involve the interacting roles of patient, medical, and communication factors, and a DD can negatively impact a patient's quality of life. Implications for physician-patient communication and public information are discussed.

Navigating the Limits of Diagnosis: Young Adults' Experiences of Chronic Living

Young adults living with chronic illness often experience considerable uncertainty across the emotional, cultural and medical spheres of their everyday lives. The process of seeking, receiving and reckoning with a diagnosis has frequently been an in-road for qualitative examinations of these experiences. As a result, the biomedical diagnosis has often taken centre stage in research concerning how uncertainty is managed and/or more stability is found. However, the significance of diagnosis can shift over time, and in many cases, the promise of diagnosis deteriorates as life unfolds. This study draws on a series of in-depth qualitative interviews with 33 young adults (ages 19-29) living with a range of chronic illnesses, which include auto-immune illnesses, fatigue syndromes and neurological conditions. Undertaking an inductive interpretative analysis based on constructivist grounded theory, we examine the role and meaning of diagnosis for our participants and find that they iteratively de-centre diagnosis in various circumstances. We suggest that while the way young adults manage chronic illness may involve seeking a diagnosis, navigating the shortcomings of diagnosis takes a significant emotional toll, and a failure to recognise this work is one important way that the experience of chronic illness when young can be misunderstood.

The role of administrative categories in the globalisation of a psychiatric concept: Case studies of autism in Japan

This paper explores how what I call 'administrative categories' have been adopted by the Japanese government and experts in autism support and what roles these categories have played in local settings. Since support practices for children and adults with autism began in the 1950s in Japan, the Japanese government and people engaging in autism support have used Japanese-specific administrative categories, instead of relying on a medical concept of autism, such as 'severe moving disabilities' (SMD), 'emotional disturbance', and 'extremely disruptive behavioural disorders' (EDBD). To understand the emergence of these three autism-related administrative categories in Japan, historical materials published from the 1950s to the 1990s by Japanese authors (doctors, psychologists, teachers, educationalists, welfare workers, government officials, and parents) and interview data with 19 leading experts of autism in Japan were collected and analysed thematically. The analysis revealed that the governmental ministries aimed to focus on establishing administrative support by avoiding engaging in aetiological debates among doctors, and to describe the political agenda more vividly. Administrative categories filled the gap between local interests and international medical concepts, enabling the concept of autism to be rooted in Japan's administrative systems. Three roles of administrative categories were identified: i) separation from medicine, ii) describing local problems, and iii) claimsmaking to wider actors and the public. I concluded that looking purely at medical and specifically diagnostic concepts limits our understanding of the formation of practices regarding disabilities, and thus more focus should be placed on categorisation practices outside of medicine. In addition, to the literature on the globalisation of Euro-American psychiatric concepts, this study contributes to our knowledge of a form of locality that has not been central in the exploration of the influence of globalisation on local settings and the relationships between the local and the global.

Adolescent dysmenorrhoea in general practice: tensions and uncertainties

This Perspectives article reflects on findings from our systematic review about adolescent dysmenorrhoea Q, drawing on sociology of diagnosis theory. We consider tensions and uncertainties between presentation with symptoms of dysmenorrhoea and processes of symptom categorisation and diagnosis in adolescents, tracing these through research and clinical guidance, considering possible implications for clinical practice. We argue that challenges in distinguishing between primary and secondary dysmenorrhoea in research translate into challenges in differentiation in clinical practice. We argue that framing this distinction as clear cut and straightforward belies the well-documented challenges in diagnosis of endometriosis, and that not recognising uncertainty and complexity inherent in this task may benefit neither clinicians nor patients.

The lived experience of French parents concerning the diagnosis of their children with borderline personality disorder

BACKGROUND

Psychiatrists often hesitate to diagnose borderline personality disorder (BPD). While individuals with BPD have reported both positive and negative experiences upon receiving their diagnosis, no study has specifically explored this issue among parents. Parents of children diagnosed with BPD can benefit from recently developed family-support interventions such as the Family Connections program. Our study aimed to explore the experiences of parents learning about their child's BPD diagnosis and to investigate the impact of the Family Connections program on their experiences.

METHODS

This qualitative study, conducted in France following the five-stage IPSE method, involved parents of children with BPD recruited through the Family Connections association in Versailles. We conducted semi-structured interviews and used purposive sampling for data collection until data saturation was reached. Data analysis was performed using a descriptive and structuring approach with NVivo 12 software to elucidate the structure of lived experiences.

RESULTS

The study included 21 parents. The structure of the lived experiences was characterized by three central axes: (1) the long and difficult road to diagnosis; (2) communicating the BPD diagnosis to parents: a necessary step; (3) the pitfalls of receiving the diagnosis. The Family Connections program provided significant support in these areas, particularly in understanding the diagnosis, enhancing communication with their child, and reducing social isolation.

CONCLUSION

These findings highlight the challenges parents face when receiving a BPD diagnosis for their child and underscore the need for an early, clear, and detailed explanation of the diagnosis. The specific experiences of receiving the diagnosis are indicative of the broader care experience parents undergo and highlight their need and right to be informed, supported, and guided throughout their child's treatment.

Signs and symptoms: Adverse events associated with a sterilization device

Sterilization is now the most common contraceptive method used by women of in the U.S., and sterilization devices have played an important role in its increased popularity. This mixed methods study examines a random sample of 2500 U.S. Food and Drug Administration (FDA) adverse event reports made between 2006 and 2017 about Essure, a sterilization device. Quantitative coding was used to examine patient problems; pain and bleeding were reported most frequently. Qualitative coding analyzed impacts of symptoms on patients' everyday lives and patients' healthcare experiences, including intimate relationships, mothering, and paid employment. Findings suggest that some patients struggled when their reported "subjective" symptoms didn't result in "objective" clinical signs of problems, and when physicians dismissed or deflected their concerns in diagnostic encounters. This paper raises important issues regarding the symptoms patients associated with Essure, the diagnosis of device-driven disease and injury, and the FDA's regulation of medical devices.

'I Do It All Alone': The Burdens and Benefits of Being Diagnosed With, and Treated for, Colorectal Cancer During the Covid-19 Pandemic

INTRODUCTION

The Covid-19 pandemic dramatically altered the way cancer care services were accessed and delivered, including for colorectal cancer (CRC). In the United Kingdom, patients were discouraged from presenting in primary care, many consultations took place remotely, investigative procedures and screening programmes were temporarily suspended, and fewer operations and treatments were delivered. People had to face the practical consequences of having cancer during a pandemic and navigate never before seen pathways, often alone. We examined the experience of being diagnosed and treated for CRC during the pandemic, and the implications of this on people's cancer journeys.

METHODS

Semi-structured interviews were undertaken with people diagnosed with CRC during the Covid-19 pandemic (January 2020-May 2021), in the North East of England. An iterative topic guide was used during interviews, which took place remotely (telephone or Zoom), were audio recorded, pseudo-anonymised and transcribed. Initial transcripts were independently coded by two researchers, and a code 'bank' developed for application across transcripts. Development of themes and overarching analytical constructs was undertaken collaboratively by the research team.

RESULTS

Interviews were conducted with 19 participants, analysed and four key themes identified: (1) The relative threats of Covid-19 and Cancer were not comparable, with cancer seen as posing a far greater risk than Covid-19; (2) Remote consultations were problematic, affecting patients' abilities to build rapport and trust with clinicians, assess nonverbal communication, and feel able to disclose, comprehend and retain information; (3) Stoma follow-up care was seen to be lacking, with long wait times for stoma reversal experienced by some; Finally, (4) Being alone during consultations negatively impacted some peoples' abilities to absorb information, and left them without the support of loved ones at an emotionally vulnerable time. However, some participants preferred being alone at certain points in their pathways, including receiving a diagnosis, and most frequently when receiving in-patient treatment.

CONCLUSION

Being alone brought unexpected benefits, absolving people from undertaking emotions work for others, and instead focus on their recovery, however, remote consultations negatively impacted patients' experiences. This study highlights the complex benefits and burdens of pandemic-located cancer journeys, including how these shifted at different points across cancer pathways.

PATIENT OR PUBLIC CONTRIBUTION

Lorraine Angell, a cancer survivor, has been central to this study from idea conception, contributing to: development of study focus and design; securing funding; production of patient-facing materials; development of interview topic guides; analysis and interpretation of data; and drafting of key findings and manuscripts.

Compelled loneliness and necessitated social isolation: "It's like being on the other side of a mirror, just looking in"

This article develops the conceptualisation of loneliness by drawing on 42 accounts of myalgic encephalomyelitis (ME). While illness experience is a central concern of the sociology of health and illness, experiences of loneliness alongside contested and chronic illness have received less attention. The analysis illustrates how loneliness can be an integral part of living with ME and offers two novel conceptual contributions - necessitated social isolation and compelled loneliness. Necessitated social isolation concerns how ME symptoms can make social lives increasingly restricted. Compelled loneliness highlights how the combined experiences of both stigma and contested illness can lead to social withdrawal and rejection, which create a sense of loneliness. The article argues that loneliness and social isolation can be conceptually distinct yet recursive and overlapping. With the worsening of ME, the participants experienced a cycle of loneliness, in which social isolation and loneliness reproduced each other. Three key themes draw attention to how loneliness is affected by the situational aspects of living with a chronic and contested illness: (1.) spatial and temporal restrictedness (2.) communicative alienation and (3.) discreditation. The article highlights how health challenges can impact on loneliness and how the stigma of contested illness exacerbates loneliness.

Normal isn't normal: On the medicalization of health

BACKGROUND

This study investigated the proportion of the U.S. population classified as healthy based on 10 common indicators, examined in two ways: (1) above or below (in the healthy direction) the sample median (termed "normal"), and (2) below diagnostic cut-off points for clinical caseness or high risk (termed "ideal").

METHODS

Data are from the 2017-March 2020 round of the National Health and Nutrition Examination Survey (NHANES). Sample sizes ranged from 3,956 to 8,961 for respective health indicators, with a total of 3,102 respondents for two weighted multi-item measures described below. Measures included the Alameda 5 health behaviors (smoking, drinking exercising, sleeping, and body mass index) and five standard biomarkers (systolic and diastolic blood pressure, resting heart rate, fasting glucose, and total cholesterol). Besides point prevalences for the normal and ideal categories for each indicator, we also calculated the proportion healthy for all 10 indicators, again calculated both ways, termed "meta-normal" and "meta-ideal."

RESULTS

The prevalence of meta-normality was 1.05%, suggesting that hardly any adult Americans are completely healthy according to population norms. Findings for meta-ideality showed that while most Americans are not clinical cases for any respective indicator, only 5.55% met the official criteria for being healthy according to all 10 indicators.

CONCLUSION

Most Americans appear healthy according to nearly all key health indicators and biomarkers, according to "normal" or "ideal" criteria. However, the proportion healthy according to all measures is extremely small. Relatively few U.S. adults are completely healthy according to clinical criteria (meta-ideal), and even fewer are completely healthy according to population norms (meta-normal). Results are interpreted through sociological writing on medicalization.

Cross-disease spillover from research funding: Evidence from four diseases

There is widespread appreciation for the role of research in addressing health problems. However, there is limited evidence on the extent to which research can be targeted to specific diseases. Analyses highlighting a concentration of research funding towards certain diseases have prompted growing scrutiny over the allocation of research funding. In this paper, we show that research funding targeted to a disease often results in publications relating to other diseases. Using data from the world's largest biomedical research funders, we estimated the frequency and direction of this cross-disease spillover by examining 337,573 grant-publication pairs for four diseases. We found the majority of our grant-publication pairs were cross-disease spillovers. We also found some variation between "rich" and "poor" diseases, in terms of the frequency and direction of cross-disease spillover. These differences are likely to be related to characteristics of the diseases themselves, as well as features of the research environment. One implication of frequent cross-disease spillover is that although more investment in areas of research such as neglected diseases is necessary, it may not be sufficient to improve the alignment between research funding and health needs.

Identification and support of autistic individuals within the UK Criminal Justice System: a practical approach based upon professional consensus with input from lived experience

BACKGROUND

Autism spectrum disorder (hereafter referred to as autism) is characterised by difficulties with (i) social communication, social interaction, and (ii) restricted and repetitive interests and behaviours. Estimates of autism prevalence within the criminal justice system (CJS) vary considerably, but there is evidence to suggest that the condition can be missed or misidentified within this population. Autism has implications for an individual's journey through the CJS, from police questioning and engagement in court proceedings through to risk assessment, formulation, therapeutic approaches, engagement with support services, and long-term social and legal outcomes.

METHODS

This consensus based on professional opinion with input from lived experience aims to provide general principles for consideration by United Kingdom (UK) CJS personnel when working with autistic individuals, focusing on autistic offenders and those suspected of offences. Principles may be transferable to countries beyond the UK. Multidisciplinary professionals and two service users were approached for their input to address the effective identification and support strategies for autistic individuals within the CJS.

RESULTS

The authors provide a consensus statement including recommendations on the general principles of effective identification, and support strategies for autistic individuals across different levels of the CJS.

CONCLUSION

Greater attention needs to be given to this population as they navigate the CJS.

Uncertainty Work: Dealing with a Psychiatric Crisis in Two European Community Mental Health Teams

The quest for how to deal with a crisis in a community setting, with the aim of deinstitutionalizing mental health care, and reducing hospitalization and coercion, is important. In this article, we argue that to understand how this can be done, we need to shift the attention from acute moments to daily uncertainty work conducted in community mental health teams. By drawing on an empirical ethics approach, we contrast the modes of caring of two teams in Utrecht and Trieste. Our analysis shows how temporality structures, such as watchful waiting, are important in dealing with the uncertainty of a crisis.

Spectralities of ADHD: hauntological diagnosis amidst agency, politics and pedagogies

Hauntology has become an increasingly alluring concept in social sciences to reflect upon everyday life and how subjects dwell upon scenarios pervaded not only by the potency of the actual but also the haunting of the past and the virtual. Drawing on the concept of 'hauntology', we inquire about recurring temporalities and spectrality themes concerning the 'controversial' diagnosis of attention deficit hyperactivity disorder (ADHD) in Chile. Using participant observation and in-depth interviews with health practitioners, teachers, school staff, diagnosed children, and their peers from 3-year-long research, we examine how the performance of the diagnosis by clinicians at times can produce a modification of the temporality of the diagnosed children from that moment forth. Amidst tension created by educational policies, ideas of well-being, pedagogical practices, and everyday living, the diagnosis keeps repeating its agentic capacity while resisting its decay, becoming ever-present and actual. Once cast, the diagnosis acts as a repeating force that can shape every experience, cancelling the possibility for the child to become different by unfolding out of the diagnosis.

Detecting value(s): Digital biomarkers for Alzheimer's disease and the valuation of new diagnostic technologies

This article explores how the meanings and values of diagnosis are being reconfigured at the interface between technological innovation and imaginaries of precision medicine. From genome sequencing to biological and digital 'markers' of disease, technological innovation occupies an increasingly central space in the way we imagine future health and illness. These imaginaries are usually centred on the promise of faster, more precise and personalised diagnosis, and the associated hope that if detected early enough disease can be effectively treated and prevented. Underpinning and reproduced through these narratives of the future is a re-conceptualisation of diagnostic processes and categories around the anticipation of future risk, as noted by recent theoretical developments in the sociology of diagnosis and related disciplines. Adding to this literature, in this article we explore what makes these emerging diagnostic arrangements valuable, to whom and how. Drawing on interviews with experts involved in the development of digital biomarkers for Alzheimer's disease, we trace how multiple and at times conflicting applications of the tools, and the value(s) attached to them, are coproduced. We thus ask what possibilities are pursued, or foreclosed, through the work of imagining the future of diagnosis.

Diagnosis and the practices of patienthood: How diagnostic journeys shape illness experiences

Sociologists have a rich history of studying the process of diagnosis and how people experience illness. Yet, the sociology of diagnosis and illness experience literatures have seldom been fully integrated. Instead, these literatures highlight one element of the illness journey, wherein scholars either primarily study diagnostic processes and categories or people's illness experiences. Drawing on empirical studies that examine diagnosis and experiences of illness in varied settings (diagnosis during breast cancer surveillance, diagnosis and experience of autoimmune illness and incarcerated women's experiences of diagnoses and illness), in this article we build on our concept of regimes of patienthood to explain how diagnostic journeys, and the relations and power dynamics that manifest during this time, shape the illness experience and practices of patienthood. We construct a classification of diagnostic processes grounded in our empirical research that span (1) sudden diagnoses, (2) long, changing diagnostic journeys and (3) diagnostic journeys marked by disbelief and denial of care. Our findings demonstrate how diagnostic journeys and illness experiences are intertwined, with different diagnostic pathways impacting how illness is experienced. Analysing these categories collectively demonstrates that diagnostic journeys, while heterogenous, shape the practices that patients develop to manage health conditions and navigate unequal health-care encounters.

Diagnosing by anticipation: Coordinating patient trajectories within and across social systems

Anticipation is a fundamental aspect of social life and, following Weber, the hallmark of social action-it means trying to take others' responses to our actions into account when acting. In this article, we propose and argue the relevance of anticipation to the sociological study of diagnosis. To that end, we introduce and elaborate on the concept of diagnosing by anticipation. To diagnose by anticipation is to consider diagnoses as cultural objects imbued with meaning, to anticipate how others will respond to their meaning in situ and to adapt the choice of diagnosis to secure a desired outcome. Unlike prognosis, which seeks to predict the development of a disease, diagnosing by anticipation entails seeking to predict the development of a case and the effect of different diagnostic categories on its trajectory. Analytically, diagnosing by anticipation therefore involves a shift in diagnostic footing, from trying to identify what the case is a case of, to trying to identify which diagnosis will yield the desired case trajectory. This shift also implies a stronger focus on the mundane organisational work of operating diagnostic systems and coordinating case trajectories within and across social systems, to the benefit of the sociology of diagnosis.

Turning Towards the Affective: Medical Semiotics of Child Maltreatment in Denmark

Signs of child maltreatment may be physical and detectable by clinical examination but may also arise as a feeling of strangeness that sparks uncertainty. Based on fieldwork in Danish general practice, and thinking along recent discussions around semiotics and affect, the article explores how feelings of "strangeness" arise in child consultations. It focuses on how subjective, embodied, and interpersonal reactions arise, how signs, however tactile and arbitrary, are felt and experienced, and how engaging with affective aspects when doing diagnosis, could expand the medical semiotics of child maltreatment.

Women's Experiences of Health-Related Communicative Disenfranchisement

Women's inequitable healthcare experiences are epistemic injustices by which women are discredited and harmed in their position as knowers of their health and their bodies. Drawing on the theory of communicative disenfranchisement (TCD), we sought to amplify voices of women experiencing communicative disenfranchisement (CD) and to unify their stories according to theoretical premises, namely, attention to power, material conditions, discourse, identities and relationships, and process. We interviewed 36 women living in the United States whose health issues have not been taken seriously by health care providers, friends, and family - pervasive sources of disenfranchising talk surrounding health. Mapping onto the TCD framework, our findings explicate the process of CD, including the material and immaterial consequences of disenfranchising talk and women's responses to such talk. CD unfolded as a protracted and often circular process of women seeking care but encountering health dismissals and minimalizations, blaming and shaming, normalizing of their pain, and psychologizing. We unpack how disenfranchising talk rendered women crazy and dehumanized them and inflicted shame and loss. Women responded to disenfranchising talk with silence, and they (re)claimed their voice by resisting psychogenic explanations for their problems, critiquing women's healthcare, asserting their needs, and advocating for others. We discuss the implications of this research for theory and praxis.

The Metamorphosis, struggling to adapt to a new condition. The lived experience of patients with Thrombotic microangiopathies diagnosed in the ICU. A qualitative study

BACKGROUND

Using qualitative interviews, our objective was to better understand the experience of patients with Thrombotic microangiopathies (TMA), from discovering their disease in the ICU to the psychological, emotional, and social specifics of living with this rare disorder.

MATERIAL AND METHODS

Patients were recruited at seven TMA centers belonging to the French national TMA referral network. A total of 15 patients, 15 relatives and 12 healthcare professionals participated. A majority of patients (n = 11/15) were women, median age was 41 (range 29-62) years, and median time elapsed since diagnosis was 6 (range 2-11) years. Interviews were analysed using thematic analysis.

RESULTS

We derived 3 major themes from qualitative analysis: 1) Discovering TMA: experiencing a life-threatening emergency with open eyes; 2) TMA: a complex and diverse disease and care plan; 3) Living with TMA: taming fear and loneliness.

CONCLUSIONS

Patients with TMA share common experiences with patients with other rare diseases, but also specific experiences related to their illness. Improved information at the onset and during the course of the illness, associated with enhanced care coordination plans would help TMA patients better cope with their illness and adhere to their care projects.

Past, present and imaginary: Pathography in all its forms

Diagnosis is a profoundly social phenomenon which, while putatively identifying disease entities, also provides insights into how societies understand and explain health, illness and deviance. In this paper, we explore how diagnosis becomes part of popular culture through its use in many non-clinical settings. From historical diagnosis of long-deceased public personalities to media diagnoses of prominent politicians and even diagnostic analysis of fictitious characters, the diagnosis does meaningful social work, explaining diversity and legitimising deviance in the popular imagination. We discuss a range of diagnostic approaches from paleopathography to fictopathography, which all take place outside of the clinic. Through pathography, diagnosis creeps into widespread and everyday domains it has not occupied previously, performing medicalisation through popularisation. We describe how these pathographies capture, not the disorders of historical or fictitious figures, rather, the anxieties of a contemporary society, eager to explain deviance in ways that helps to make sense of the world, past, present and imaginary.

What rare cancers have in common. The making of lists of (very) rare cancers and the coordination of medical work

This article aims to understand why medical actors recently published lists of rare and very rare cancers. It studies four lists of rare and very rare cancers based on interviews with the main actors on these lists and an analysis of medical articles in which these lists were published. It argues that these lists constitute boundary objects whose aim is to deal with the organizational challenges raised by precision medicine, which imply increasing the coordination work between various types of actors. Our work therefore allows a better understanding of the functioning of the recursive standardization process of a boundary object and, by analyzing how the category of rarity is built at the intersection of both professional and nosographic principles, shows the intertwining of the biomedical, organizational, and political aspects on which rests the practice of contemporary precision medicine.

Not all diagnoses are created equal: Mothers' narratives of children, ADHD, and comorbid diagnoses

Social research examining patients' and caretakers' narration of mental disorders, including ADHD, has been remarkably silent about comorbidity. Centering the theme of uncertainty and the question of what is "at stake" in mothers' mental health narratives of children (Kleinman, 1988), we characterize the patchwork process by which mothers deploy ADHD and comorbid diagnoses to account for key experiences and struggles in their and their child's lives. We found that ADHD had limited purchase in accounting for the emotional and social difficulties that were most urgent in mothers' narratives, despite the medical authority behind the ADHD label, which the mothers mostly accepted. However, mothers remained pervasively uncertain about the relationship between ADHD and comorbid mental health conditions, paralleling debates on the relationship between ADHD, emotion, and comorbidity in the psychiatric and psychological literature. Our findings contribute a conceptualization of comorbidity as a web of diverse moral vocabularies, institutional outcomes and perceptions of personhood, through which mothers of ADHD children maneuver over time. Through this perspective we illustrate how ADHD is co-constructed as a narrow neurological problem of 'attention,' and demonstrate the overlooked and crucial ways that comorbidity may shape parents' pragmatic and interpretive negotiation of ADHD. Kleinman, Arthur. (1988). The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.

Adequate trials: How the search for a cure shaped leukemia diagnosis

This article examines the relationship between diagnosis and therapy, focusing on the case of leukemia and cancer chemotherapy in the 1960s. This case, I argue, reinforces the need to study diagnoses from a social-science perspective, because the persistent controversy around leukemia classification was resolved by institutional restructuring introduced through clinical experimentation, rather than by techno-scientific advances. In an attempt to prove that chemical cancer therapy was possible, oncologists replaced the question 'Is this drug working?' with the question 'How can we make this drug work?' To create the conditions and criteria under which drugs could work, oncologists undertook the reclassification of cancers and patients, producing a new diagnostic style that reversed the roles of diagnosis and therapy. Experts gained and secured the power to classify not by solving existing problems, but by redefining what counts as a problem and what qualifies as a solution. Similarly, therapies can become transformative not only when they 'work', but when they work just well enough to mobilize resources and support. Theorizing these displacements, I develop the concept of 'adequate trials' in order to capture modes of innovation in which a deep commitment to give new technologies a 'fair chance' to succeed (i.e. an 'adequate trial') leads experts to redefine the tasks and goals of their field. To further our theoretical understanding of how rigid drug testing becomes malleable and conducive to normative change, I analyze the organizational, scientific, and jurisdictional conditions that gave rise to oncologists' practical orientations.

Preliminary efficacy of cognitive-behavioral therapy on emotion regulation in adults with autism spectrum disorder: A pilot randomized waitlist-controlled study

Previous studies have demonstrated the clinical utility of cognitive-behavioral therapy in improving emotion regulation in children on the autism spectrum. However, no studies have elucidated the clinical utility of cognitive-behavioral therapy in improving emotion regulation in autistic adults. The aim of the present pilot study was to explore the preliminary clinical utility of a group-based cognitive-behavioral therapy program designed to address emotion regulation skills in autistic adults. We conducted a clinical trial based on a previously reported protocol; 31 participants were randomly allocated to the intervention group and 29 to the waitlist control group. The intervention group underwent an 8-week program of cognitive-behavioral therapy sessions. Two participants from the intervention group withdrew from the study, leaving 29 participants (93.5%) in the group. Compared with the waitlist group, the cognitive-behavioral therapy group exhibited significantly greater pre-to-post (Week 0-8) intervention score improvements on the attitude scale of the autism spectrum disorder knowledge and attitude quiz (t = 2.21, p = 0.03, d = 0.59) and the difficulty describing feelings scale of the 20-item Toronto Alexithymia Scale (t = -2.07, p = 0.04, d = -0.57) in addition to pre-to-follow-up (Week 0-16) score improvements on the emotion-oriented scale of the Coping Inventory for Stressful Situations (t = -2.14, p = 0.04, d = -0.59). Our study thus provides preliminary evidence of the efficacy of the group-based cognitive-behavioral therapy program on emotion regulation in autistic adults, thereby supporting further evaluation of the effectiveness of the cognitive-behavioral therapy program in the context of a larger randomized clinical trial. However, the modest and inconsistent effects underscore the importance of continued efforts to improve the cognitive-behavioral therapy program beyond current standards.

The hidden burden of medical testing: public views and experiences of COVID-19 testing as a social and ethical process

BACKGROUND

In May 2020, the Scottish Government launched Test and Protect, a test, trace and isolate programme for COVID-19 that includes a PCR testing component. The programme's success depended on the willingness of members of the public to seek out testing when they experienced symptoms and to comply with guidelines on isolation should they test positive. Drawing on qualitative interview-based research, this paper analyses public understandings, expectations, and experiences of COVID-19 testing during the early stages of the programme. Through anthropological and sociological analysis of the findings we aim to contribute to social understandings of COVID-19 testing practices; and to inform the design of population level testing programmes for future pandemics.

METHODS

Between 7 July and 24 September 2020, 70 semi-structured interviews were conducted with members of the general public (aged 19-85) living in the Lothian region of Scotland. Interviews were held online or by telephone, were transcribed verbatim and analysed using thematic analysis informed by anthropological and sociological theories of medical testing.

FINDINGS

Social relationships and ethical considerations shape testing practices at every stage of the testing process. Members of the public viewed testing as a civic duty to society and moral duty to friends, family, and colleagues. However, the testing process also placed a significant social, economic, and practical burden on the individual and sometimes generated competing obligations. Many participants experienced a disconnect between the government's portrayal of testing as easy and the everyday burden of testing.

CONCLUSIONS

COVID-19 testing is experienced as a social process shaped by multiple relationships and ethical considerations. The full burden of testing should be considered in the design of future testing programmes.

Unsettling experiences: A qualitative inquiry into young peoples’ narratives of diagnosis for common skin conditions in the United Kingdom

Skin conditions such as eczema and psoriasis are relatively prevalent health concerns in children, adolescents and young adults. Experiences of these dermatology diagnoses in adolescence have hitherto not been the focus of research, perhaps owing to assumptions that these diagnoses are not particularly impactful or intricate processes, events or labels. We draw on a thematic secondary analysis of in-depth interviews with 42 adolescents and young people living in the United Kingdom and, influenced by the sociologies of diagnosis and time, highlight the psychological, emotional, social and temporal complexities involved in their diagnosis experiences. Firstly, we describe how participants remembered, re- and co-constructed their diagnosis experiences during the interview. Secondly, we explore the pace and rhythm of diagnosis, including mis-diagnoses, highlighting the jarring potential for adolescents on being diagnosed, even for conditions typically deemed minor. Thirdly, we consider the ways in which these diagnoses have the capacity to reformulate notions of past, present and future, including projecting into imagined futures and reinterpreting past bodily sensations. Finally, we examine how memories about and the meaning of diagnosis are revisited, revised and potentially replaced as a child or adolescent grows older, and increases their management of their condition and encounters with healthcare professionals. In unsettling an assumption that diagnosis experiences for adolescents of common skin conditions is unproblematic or straightforward, our qualitative analysis critically engages with and contribute to tenets of health research that are of interest to quantitative and qualitative researchers, clinicians and patients.

Care entanglements: Upholding difference through the uses of mental health diagnosis in Chilean schools

This article draws upon findings from fieldwork conducted with Chilean mental health practitioners and school staff to explore how children's mental health diagnoses can be used in the school setting as a particular rationale to mobilise and convey new forms of care practices (Mol, The logic of care: Health and the problem of patient choice, 2008). Inspired by the framing of care as an interrelational, interdependent and more-than-human affair promoted by Science and Technology Studies, and drawing from conceptual tools offered by post-humanist approaches, we focus our examination on the diagnosis of attention deficit-hyperactivity disorder (ADHD). Following the diagnosis since its formulation by clinicians in the public sector to its enactment in an urban school in Santiago, Chile, we explore how certain caring/uncaring practices are enacted in relation to the diagnosis, reconfiguring the classroom by incorporating (non)human actors to care for the diagnosed child. However, care is ambivalent, and the diagnosis can be put into action for other purposes as it interweaves with educational policies and other agendas. Thus, to produce policies that truly foster inclusion, attention must be given to the micropolitical level where disabilities and disorders are enacted, developing appropriate ethico-political and affective sensitivities to care accordingly.

Neurasthenia and autonomic imbalance as minor diagnoses: comparison, concept and implications

A new term, autonomic imbalance (自律神經失調 or AI), which refers to a wide variety of physical and mental symptoms that are medically unexplained, has recently emerged in Taiwan. Many people compared this condition to neurasthenia, a now obsolete diagnosis. Whether neurasthenia and AI are medically the same or merely similar is a debate that is better left to clinicians; however, this article endeavours to explore the significance of the comparability in terms of socio-cultural theory of health. With Deleuze and Guattari’s notion of minor literature as reference, the objectives of this paper are as follows: to address how and why neurasthenia and AI should be treated as ‘minor diagnoses’ and consequently expose the limitations of current clinical medicine; to provide and discuss reasons why AI can be seen as a reincarnated form of neurasthenia; and to further elaborate how this approach may elevate inquiries on the varieties of medically unexplained symptoms to highlight the bodies that suffer without a legitimate name.

Plastic diagnostics: The remaking of disease and evidence in personalized medicine

Politically authorized reports on personalized and precision medicine stress an urgent need for finer-grained disease categories and faster taxonomic revision, through integration of genomic and phenotypic data. Developing a data-driven taxonomy is, however, not as simple as it sounds. It is often assumed that an integrated data infrastructure is relatively easy to implement in countries that already have highly centralized and digitalized health care systems. Our analysis of initiatives associated with the Danish National Genome Center, recently launched to bring Denmark to the forefront of personalized medicine, tells a different story. Through a "meta-taxonomy" of taxonomic revisions, we discuss what a genomics-based disease taxonomy entails, epistemically as well as organizationally. Whereas policy reports promote a vision of seamless data integration and standardization, we highlight how the envisioned strategy imposes significant changes on the organization of health care systems. Our analysis shows how persistent tensions in medicine between variation and standardization, and between change and continuity, remain obstacles for the production as well as the evaluation of genomics-based taxonomies of difference. We identify inherent conflicts between the ideal of dynamic revision and existing regulatory functions of disease categories in, for example, the organization and management of health care systems. Moreover, we raise concerns about shifts in the regulatory regime of evidence standards, where clinical care increasingly becomes a vehicle for biomedical research.

"I Think I Have Enough for Now": Living with COVID-19 Antibodies in the Philippines

Drawing on face-to-face and virtual fieldwork in the Philippines, I document the emergence of antibody testing as a popular practice among Filipinos during the COVID-19 pandemic, helping them make decisions about vaccines and other life choices. Antibodies gave people a sense of agency and control amid a health crisis for which political and medical authorities failed to offer certainty and hope, particularly at a time of vaccine scarcity and viral surges. However, by diverting attention from the health care system to individual immune systems, antibodies also reinforced the individual "responsibilization" that has characterized the Philippine government's pandemic response.

The diagnostic odyssey: insights from parents of children living with an undiagnosed condition

Background

People living with rare disease often have protracted journeys towards diagnosis. In the last decade, programs have arisen around the world that are dedicated to ending this ‘diagnostic odyssey’, including the Undiagnosed Diseases Program Western Australia (UDP-WA), which has a focus on finding diagnoses for children and young adults. To explore the lived experience of the diagnostic journey semi-structured interviews were conducted with parents of 11 children at commencement of their involvement in the UDP-WA.

Results

Thematic analysis revealed three main themes that captured parents’ experiences and perspectives. Parents reported (i) the need to respond to significant care needs of their children, which span not only the health system but other systems such as education and disability services. In doing so, parents become the navigator, expert and advocate for their children. Meanwhile, parents are on (ii) the diagnostic odyssey—the rollercoaster of their journey towards diagnosis, which includes various names applied to their child’s condition, and the impact of no diagnosis. Parents described their views on (iii) the value of a diagnosis and the outcomes they expect to be associated with a diagnosis.

Conclusion

Analysis showed an overall significant perceived value of a diagnosis. Our study provides new perspectives on the concept of diagnosis and indicates that parents may benefit from supports for their child’s care needs that are beyond the scope of the UDP-WA.

Acknowledging and addressing the many ethical aspects of disease

Diseases change the life of individuals, the social status of groups, the obligations of professionals, and the welfare of nations. Disease classifications function as a demarcation of access to care, rights, and duties. Disease also fosters social stigmatization and discrimination, and is a personal, professional, and political matter. It raises a wide range of ethical issues that are of utmost importance in patient communication and education. Accordingly, the objective of this article is to present and discuss a range of basic ethical aspects of this core concept of medicine and health care. First and foremost, disease evokes compassion for the person suffering and induces a moral impetus to health professionals and health policy makers to avoid, eliminate or ameliorate disease. The concept of disease has many moral functions, especially with respect to attributing rights and obligations. Classifying something as disease also has implications for the status and prestige of the condition as well as for the attitudes and behavior towards people with the condition. Acknowledging such effects is crucial for avoiding discrimination and good communication. Moreover, different perspectives on disease can create conflicts between patients, professionals and policy makers. While expanding the concept of disease makes it possible to treat many more people for more conditions - earlier, it also poses ethical challenges of doing more harm than good, e.g., in overdiagnosis, overtreatment, and medicalization. Understanding these ethical issues can be difficult even for health professionals, and communicating them to patients is challenging, but crucial for making informed consent. Accordingly, acknowledging and addressing the many specific ethical aspects of disease is crucial for patient communication and education.

Framing the Detection of Incipient Tuberculosis Infection: a qualitative study of political prioritization

Objective

Incipient Tuberculosis (ITB) refers to Mycobacterium tuberculosis infection that is likely to progress to active disease in the absence of treatment, but without clinical signs, symptoms, radiographic or microbiological evidence of disease. Biomarker‐based tests to diagnose incipient TB hold promise for better prediction and, through TB preventive therapy, prevention of disease. This study explored current and future framing and prioritisation of ITB.

Methods

Twenty‐two interviews across eight countries were conducted. A modified Shiffman & Smith Framework, containing four categories—Ideas, Issue Characteristics, Actor Power, and Political Contexts—was used to analyse the current landscape and potential for prioritisation of diagnosis and treatment of ITB.

Results

Latent TB policy implementation has been slow due to technical, logistical and financial challenges, and because it has been framed in a manner non‐conducive to gaining political priority. Framing ITB testing as ‘early detection’ rather than ‘prediction’, and its management as ‘treatment’ rather than ‘preventive therapy’, may help raise its importance in policies, and its acceptance among actors.

Conclusion

Consensus surrounding the framing of ITB will be crucial for the successful adoption of ITB diagnostics and treatment. When designing ITB tools and policies, it will be important to address challenges that pertain to latent TB policies.

Too big, too young, too risky: How diagnosis of the foetal body determines trajectories of care for the pregnant woman in pre-viability second trimester pregnancy loss

Women in the English National Health Service facing pre-viability second trimester pregnancy loss through foetal death, premature labour or termination of pregnancy for foetal anomaly find themselves in a particular trajectory of care. This usually involves the requirement to labour and birth the foetal body and may involve undergoing feticide in cases of termination. Drawing on ethnographic research investigating women's experiences of second trimester pregnancy loss, I argue that the determining factor affecting care trajectories for the pregnant body is the biomedically diagnosed status of the foetal body. Foetal size, non-viability and the potential for live birth during terminations all structure the healthcare options for the woman facing pregnancy loss in the second trimester. As such, the diagnostic classification of the foetal body in the context of gestational time determines the medical care afforded to the pregnant body. This results in specific consequences for women, whose experiences of, and choices around, second trimester pregnancy loss are constrained by diagnostic and classificatory decisions around the status of the foetal being before legal viability.

How Does It Feel to Have One's Psychiatric Diagnosis Altered? Exploring Lived Experiences of Diagnostic Shifts in Adult Mental Healthcare

BACKGROUND

Though the socio-emotional significance of psychiatric diagnoses and the frequency of transitions between diagnostic classifications are widely acknowledged, minimal research reveals how "diagnostic shifts" are subjectively experienced by psychiatric service-users.

AIM

This study investigated how adult service-users make sense of diagnostic shifts and their impacts on one's life.

METHODS

Twenty-seven people with self-reported experiences of diagnostic shifts opted into this qualitative study. Virtual narrative interviews invited participants to share their "diagnosis stories." Interview transcripts were analyzed using narrative thematic analysis to identify common and divergent experiences across participants.

RESULTS

Diverse experiences of diagnostic shifts were related: diagnostic shifts could both promote and undermine clinical trust, therapeutic engagement and self-understanding. The analysis suggested that shared and divergent experiences could be attributed to two dimensions of narratives: participants' Interpretations of Diagnostic Shifts and Diagnosis-Specific Factors. Regarding the former, analysis produced a typology of three possible interpretations of diagnostic shifts, which were linked with consistently different antecedents, experiences and consequences. The latter dimension captured how experiences of diagnostic shifts also hinged on the unique meanings ascribed to the specific diagnoses gained and lost, particularly in relation to their perceived severity, stigma, personal associations, and related communities.

CONCLUSIONS

Findings revealed how diagnostic shifts can be experienced as both traumatic and life-enhancing, depending on their social and subjective context. Understanding the range and predictors of variable experiences of diagnostic shifts is vital for sensitive clinical practice and communication.

The making and unmaking of Hashimoto's thyroiditis: On the mismatch between illness and disease. Results from an Italian study

The diagnostic process in contemporary medical practice is increasingly technical, specialised and relying on population-based ranges of biological normalcy. Disease is defined according to a hierarchy of evidence that privileges specialist knowledge and marginalises subjective experiences of illness. Medical and individual definitions of the situation can conflict in two ways: (i) a diagnosis is made in the absence of symptoms, (ii) individual suffering does not constitute 'real' disease if it is not validated by scientific evidence. This article investigates how the discrepancy between specialist and embodied knowledge is experienced and tentatively solved by patients' self-narratives. Starting from the analysis of 22 in-depth interviews with people affected by autoimmune diseases, we focus on the subgroup affected by Hashimoto's thyroiditis. Applying the most-different-systems design, we confront two flesh-and-blood ideal-types of illness narratives characterised by a mismatch between illness and disease. Their diagnostic trajectories are outlined and discussed as poles of a continuum of experiences resulting from different configurations of medical evidence of disease and subjective evidence of illness.

Politicized disease surveillance: A theoretical lens for understanding sociopolitical influence on the monitoring of disease epidemics

Sociopolitical forces commonly influence the collection, analysis, dissemination, and general perceptions of epidemiological information. Yet few theoretical lenses provide insight into the mechanisms through which such influence occurs. In this article, I draw and expand upon empirical findings to propose a novel theoretical lens, politicized disease surveillance, which I define as extreme or undue sociopolitical influence on public health surveillance systems or processes in ways that impact disease incidences and prevalences, or estimates or perceptions thereof. This lens foregrounds disease incidence and prevalence as objects of contestation and policy influence and articulates how certain facets of sociopolitical forces shape disease incidences and prevalences-especially amid an epidemic-through one or more channels: (1) the diagnostic construct; (2) screening tools, procedures, or systems; or (3) the behaviors of individuals who are living with or at risk for a certain disease. I provide several contemporary illustrations of politicized disease surveillance and discuss its theoretical and practical implications.

"Communitas in Crisis": An Autoethnography of Psychosis Under Lockdown

In this article, I use autoethnography to examine time spent on an acute psychiatric ward during the COVID-19 lockdown. I employ the device of "communitas in crisis" to emphasize the precarious nature of this experience and the extent to which, for myself at least, informal social interactions with fellow patients and "communitas" were significant features of my hospital experience and subsequent discharge. I suggest that a lack of emphasis on inpatient to inpatient relationships in the recovery literature is an omission and a reflection of psychiatry's authority struggles with both service users and professionals, along with a general perception of psychosis as individual rather than as a socially constructed phenomenon. I also suggest that, especially in the wake of greater social distancing, mental health and social services should safeguard against psychological and social isolation by creating more spaces for struggling people to interact without fear or prejudice.

Cultivated co-production: Sexual health, human rights, and the revision of the ICD

STS scholars frequently have shown how science and sociopolitical arrangements are 'co-produced', typically tracing how scientific actors themselves keep 'science' and 'politics' far apart. Revealing co-production is therefore deemed the work of the STS analyst, who unearths linkages that the actors might be unaware of, or might ignore or deny. By contrast, the creation of a new chapter on 'sexual health' in the recent revision of the International Classification of Diseases (ICD) offers a case of what might be termed 'cultivated co-production'. Neither oblivious to the linkages between science and politics nor invested in obscuring them, the designers of the sexual health chapter sought support for their work by demonstrating, transparently, how science, ethics, and human rights might properly be aligned. The intentional and visible character of co-production in this case indicates awareness of the need to manage the contested nature of gender and sexuality at a transnational level. It also reflects two changes in the organization of medical politics and medical classification: a widespread recognition of the necessity of reaching out to lay stakeholders and advocates, and the rise of an emphasis on 'conventions' as the backbone of transnational biomedical consensus processes.

Diagnostic layering: Patient accounts of breast cancer classification in the molecular era

Social scientific work has considered the promise of genomic medicine to transform healthcare by personalising treatment. However, little qualitative research attends to already well-established molecular techniques in routine care. In this article we consider women's experiences of routine breast cancer diagnosis in the UK NHS. We attend to patient accounts of the techniques used to subtype breast cancer and guide individual treatment. We introduce the concept of 'diagnostic layering' to make sense of how the range of clinical techniques used to classify breast cancer shape patient experiences of diagnosis. The process of diagnostic layering, whereby various levels of diagnostic information are received by patients over time, can render diagnosis as incomplete and subject to change. In the example of early breast cancer, progressive layers of diagnostic information are closely tied to chemotherapy recommendations. In recent years a genomic test, gene expression profiling, has become introduced into routine care. Because gene expression profiling could indicate a treatment recommendation where standard tools had failed, the technique could represent a 'final layer' of diagnosis for some patients. However, the test could also invalidate previous understandings of the cancer, require additional interpretation and further prolong the diagnostic process. This research contributes to the sociology of diagnosis by outlining how practices of cancer subtyping shape patient experiences of breast cancer. We add to social scientific work attending to the complexities of molecular and genomic techniques by considering the blurring of diagnostic and therapeutic activities from a patient perspective.

What is in a name? Autonomic imbalance and medically unexplained symptoms in Taiwan

Medically unexplained symptoms (MUS) are persistent bodily symptoms without known pathology. An unofficial term has recently emerged in Taiwan to accommodate MUS: autonomic imbalance (AI). AI literally refers to disturbances of the autonomic nervous system (ANS) that innervates vital organs. However, AI is variously conceptualised by different parties. This study intends to investigate what is in the name of AI. It draws on available databases and in-depth interviews with AI sufferers and Western and Chinese medicine physicians. Some physicians research ANS functions through heart rate variability measurements. Research findings show that physicians regard AI as a convenient term for clinical communication and a euphemistic substitute for MUS or even psychiatric diagnoses. It is not a 'real thing'. However, AI sufferers treat AI as a bona fide disease, only that it has not been officially classified. AI is therefore an unfaithful translation, or an uncontrolled equivocation, of MUS. The paper concludes by discussing the implications of treating AI as an equivocation. These implications include the limitations of the current diagnostic criteria, the necessity to rethink the dichotomy of mind and body, and the underlying realities exposed or masked by 'diagnosis'.

Becoming a diagnostic agent: A collated ethnography of digital-sensory work in caregiving intra-actions

Sociological contributions on digital health have acknowledged the enduring significance of sensory work in diagnosis and practices of care. Previous explorations of these digital and sensory entanglements have focused separately on healthcare providers or patients/caregivers, rarely bringing these worlds together. Our analysis, based on the collation of ethnographic fieldwork in clinics, medical schools, and homes in Australia, offers rare insights into caregiver and practitioner perspectives. We interrogate the work involved in digital-sensory becoming, as caregivers (in our case parents) learn to assign diagnostic meaning to potential childhood disease. Working with Karen Barad's concept of 'intra-action', we demonstrate how diagnostic knowing is enacted between practitioners, parents, senses, and devices. We identify seven aspects of digital-sensory learning: attention to the change from normal; testing/searching for signs and symptoms; confirmation and direction from more experienced others; mimicry; analogy/metaphor; digital archiving; and reference to validated digitised signs. We found that this learning does not take place discretely in the clinic or at home. Doctors and parents both do digital-sensory work to register, co-witness, and mutually enact disease by interpreting signs and symptoms together in their caregiving intra-actions. Our article also champions collated ethnography as a methodological approach for making sense of complex assemblages in healthcare.

Definitely Maybe: New Governance of Uncertainty and Risk in Patient Group Involvement with UK Guidance on Testing for Lyme Disease

States that claim responsibility for citizens’ healthcare try to deal with knowledge uncertainties while preserving a duty of care. Production of clinical guidelines in disputed medical conditions or where uncertainty is high, is difficult. Patient groups may advocate non-credentialed evidence, contribute to debates and form alliances with established policy actors. In this context, Lyme disease, especially highly contested ‘chronic’ Lyme disease is a good case with which to examine how official governance institutions are managing diagnostic uncertainty and evidence for tests. The healthcare state has been provoked to develop extensive policy for Lyme disease. In the UK, national Health Technology Assessment agency, NICE, began a consultation process in 2016. NICE and other policy actors are moving towards more participatory modes of decision-making. The article analyses NICE’s recently published guidelines and consultation documents; patient groups’ contributions; observations of consultations and of evidence review processes; and recent Department of Health systematic reviews, including patient group participation. We draw on concepts of participatory governance, patient group activism and guideline involvement. We find an increased level of participation by patient groups in recent policy and evidence review processes, and hence legitimation of them as ‘stakeholders’, alongside a strengthened state position on pre-existing diagnostic and testing standards.

Testing and Diagnosis as Social Interventions: An Interview with Annemarie Jutel

Kiran Pienaar (KP) and Alan Petersen (AP): Thank you, Annemarie, for agreeing to share your perspectives in this interview. We are delighted to have this opportunity to engage with your insights and scholarly contributions on the sociology of diagnosis.

In 2011 you co-edited a special issue of Social Science and Medicine entitled ‘Toward a Sociology of Diagnosis’ in which you called for sociologists to pay more attention to medical diagnosis as a central practice and classification tool of medicine. In the introduction, you note that ‘diagnosis has had an absent presence in the sociology of health and illness’ (Jutel & Nettleton, 2011, p. 793). Do you think this is still the case or has the field developed since then to attend more closely to the social issues and processes at work in diagnosis? In your view, does diagnosis merit continued/renewed sociological attention? And if so, why?

Between diagnostic precision and rapid decision-making: Using institutional ethnography to explore diagnostic work in the context of Cancer Patient Pathways in Norway

Alongside other Nordic countries, the Norwegian government has introduced Cancer Patient Pathways (CPPs) for faster diagnostic assessment and timely treatment to improve the quality of cancer care. A key aspect of CPPs is the introduction of time limits for each phase of the diagnostic investigation. Occurring simultaneously are ongoing advances in medical technology, complicating the process of diagnosing and treating cancer. In this article, using institutional ethnography, we examine: how does the CPP policy influence physicians' experiences of diagnostic work? Data were collected from May 2018 to May 2019, through semi-structured interviews with physicians across five hospitals in Norway (N = 27). Our findings indicate that the implementation of various strategies aimed at enhancing quality in cancer care collide, compelling physicians to negotiate between diagnostic precision and rapid decision-making. We conclude that attention to interfaces between multiple guidelines and their implications for practice is crucial for understanding and developing quality of care.