Explaining medically unexplained symptoms

Stigmatisation in clinical consultations for persistent physical symptoms/functional disorders: A best fit framework synthesis

INTRODUCTION

Stigma is a social attribute that links a person to an undesirable characteristic and leads to actions that increase the social distance from that person. This includes different or discriminatory treatment. Stigma is common in healthcare, particularly in people with persistent physical symptoms (PPS) and functional disorders (FD). The aim of this study is to create a new actionable framework to aid understanding of stigmatisation in consultations about PPS/FD and to improve the consultation experiences.

METHODS

This framework development used the Best Fit Framework approach to data collected for a scoping review of stigma in functional disorders. The stages included selection of an initial framework from existing conceptual models, mapping quote data from published papers to the framework and an iterative process of revision and re-mapping. The final framework was tested by re-mapping all the quote data to the framework following classification rules.

RESULTS

253 quotes were obtained from the results sections of qualitative studies from a previous scoping review. The framework comprises of prejudice, stereotypes and actions to increase social distance. Stereotype refers to the focus of stigma: this may be the condition, the patient, or their behaviour. Actions that increase social distance include: othering; denial; non-explanation; minimising, norm-breaking; and psychologising. By breaking down stigma into recognisable components, the framework provides a way to understand the difficulties that patients and clinicians face during consultations and a way to develop intervention materials.

CONCLUSIONS

This new framework for stigma in clinical consultations for PPS/FDs provides a useful tool for the study of stigma in clinical consultations.

Barriers to healthcare and a 'triple empathy problem' may lead to adverse outcomes for autistic adults: A qualitative study

LAY ABSTRACT

Autistic people live with more mental and physical health conditions and, on average, die younger than non-autistic people. Despite widespread commitments to tackling these issues, autistic people still report various barriers to accessing healthcare. This article aims to explore the area in depth, from the perspective of autistic people. This research benefits from being led by autistic people, for autistic people - all of the researchers are autistic, and most of us are also medical doctors. Data, in the form of written comments and stories, were collected as part of a large survey. Here, we explored these for common themes and possible deeper meaning within the experiences. People who took part reported a variety of barriers. Here, our article gives voice to their stories, in their own words. Themes included: early barriers; communication mismatch; doubt - in oneself and from doctors; helplessness and fear; and healthcare avoidance and adverse health outcomes. Our findings allowed us to create a model that aimed to understand and explain the reported barriers in the context of the previously known consequences. We also built on wider autism theories to explain our findings in more depth.

Physicians' Explanatory Models of Pediatric Inflammatory Bowel Disease: A Qualitative Interview Study

Explanatory models are culturally informed representations of illness that convey understandings of the etiology and expected course of disease. Substantial research has explored lay explanatory models, but examining physicians' clinical explanatory models can also provide insight into patients' understandings of illness because physicians are a foundational source of authoritative knowledge that shapes lay concepts of illness and disease. This study characterized the explanatory models used by pediatric gastroenterologists when explaining inflammatory bowel disease (IBD) to children. We conducted semi-structured qualitative interviews with 20 pediatric gastroenterologists across the United States about their clinical communication and explanatory models. We identified two primary explanatory models used to describe immune dysregulation in pediatric IBD: the defense and protection model, which characterizes the immune system as an army that erroneously sees the body as "non-self" and attacks it; and the switch model, which conceptualizes treatment as activating a switch that turns off a faulty immune response. We also identified two models used by some physicians to describe inflammation: the scratch and scrape model, which compares IBD inflammation to scratches or scrapes on the skin; and the bonfire model, which compares inflammation to a fire in need of extinguishing. While the use of militaristic metaphors is pervasive in medicine, describing autoimmunity as a battle against the self may lead children to perceive their body as the enemy. This may be compounded by describing the immune system as "confused" while noting its ongoing protective function. Use of these explanatory models may nevertheless improve patient disease-related knowledge.

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Vague sensations. About the background and consequences of discordance between actual and perceived physiological changes

Empirical evidence consistently shows that discordance, also called dissociation or discrepancy, between actual physiological (mainly visceral) events and their perceived counterparts is substantial. On the one hand, we typically do not perceive actual visceral events occurring in our bodies; on the other hand, sometimes we do perceive bodily changes that do not really take place. This narrative review presents the available empirical findings on the discordance, and summarizes possible explanations that approach the phenomenon from the viewpoint of evolution, cognitive development, and predictive processing. Also, the role of top-down factors, such as expectations and experiences is discussed. Finally, practically relevant consequences of the discordance are presented using the examples of mind-body practices, the placebo and nocebo phenomenon, and medically unexplained symptoms. It is concluded that the discordance between actual and perceived body changes can have a negative impact on health, mainly through issues with adherence and other behavioral factors. The existence of actual-perceived discordance should be taught and demonstrated in the elementary and high school, as well as in many areas of higher education.

Folie et Société: eroding the body-mind relationship via dysfunctional paternalistic systems

This theoretical perspective examines the proposition of shared complex trauma between a parent and child, arising from blurred relational boundaries and societal oppression, leading to inequality both at home and within the larger paternalistic system of society. Specifically, the focus is on living within a paternalistic, authoritarian system where rules are unjust, demanding obedience and compliance without questioning the behaviors of the authority. Individuals growing up in these circumstances are subject to adverse and emotionally overwhelming experiences, which lead to the creation of emotional memory images (EMIs). The delusion in which the child is caught up becomes a reality for the child as time passes. This phenomenon is recognized in psychiatry as "Folie à deux" (the madness of two or more) at the micro level, and "Folie et Société" (the madness of society) on the macro level. Complex trauma, derived from a child's exposure to multiple adverse events, can erode the mind-body relationship, impacting both mental and physical health. These traumatic experiences in early childhood can manifest as body-focused disorders in adolescents, prevailing throughout adulthood if left unattended. This article provides a theoretical perspective on dealing with the dissociation and chronic stress related to oppressive and authoritarian family systems. The broader implications of this article include highlighting the psychophysiological underpinnings of complex trauma, the relationship of a highly oppressive paternalistic authoritarian system imposed on children and adolescents, and the role of Split-Second Unlearning as a therapeutic intervention to clear EMIs and improve overall health outcomes.

Acquiring a new understanding of illness and agency: a narrative study of recovering from chronic fatigue syndrome

BACKGROUND

The condition known as chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is poorly understood. Simplified medical models tend to neglect the complexity of illness, contributing to a terrain of uncertainty, dilemmas and predicaments. However, despite pessimistic pictures of no cure and poor prognosis, some patients recover.

PURPOSE

This study's purpose is to provide insight into people's experiences of suffering and recovery from very severe CFS/ME and illuminate understanding of how and why changes became possible.

METHODS

Fourteen former patients were interviewed about their experiences of returning to health. A narrative analysis was undertaken to explore participants' experiences and understandings. We present the result through one participant's story.

RESULTS

The analysis yielded a common plotline with a distinct turning point. Participants went through a profound narrative shift, change in mindset and subsequent long-time work to actively pursue their own healing. Their narrative understandings of being helpless victims of disease were replaced by a more complex view of causality and illness and a new sense of self-agency developed.

DISCUSSION

We discuss the illness narratives in relation to the disease model and its shortcomings, the different voices dominating the stories at different times in a clinically, conceptually, and emotionally challenging area.

Being Caught in a Vicious Circle: An Interview Study of Individuals Suffering From Grade II-IV Hiatal Hernia

Large paraesophageal hernias are related to life-threatening complications that warrant immediate surgery. Whether the long-standing chronic symptoms related to the disease in individuals without hernia incarceration motivate surgical treatment is still a subject for discussion. The aim of this study was to explore how individuals suffering from Grade II-IV hiatal hernia describe their symptoms and health, as well as how the disease affects their life. Semistructured interviews were performed with 22 individuals planning to undergo surgery for a large paraesophageal hernia. The data were analyzed using qualitative content analysis and resulted in one main theme "Being caught in a vicious circle" and six subthemes "Distressing and uncertain times," "The symptoms have seized control over my health," "Loss of energy and strength," "Strategies for managing daily life," "Loss of social life," and "Moments of hope despite failing health." Central to the participants' descriptions is their commitment to strategies for managing the ever-present and unpredictable symptoms that have seized control over their health. They were trapped in a hopeless and isolated existence, that is, a vicious circle, from which they were unable to escape. Despite the low incidence of volvulus and incarceration, the symptom burden and effect on general health motivate treatment in these individuals.

Clinician Interruptions and Patient-Rated Clinician Empathy in Specialty Visits

INTRODUCTION

Clinicians tend to interrupt patients when they are describing their problem, which may contribute to feeling unheard or misunderstood. Using transcripts of audio and video recordings from musculoskeletal (MSK) specialty visits, we asked what factors are associated with (1) Perceived clinician empathy, including the time a patient spends describing the problem and time to the first interruption, (2) duration of patient symptom description, and (3) duration between the end of greeting and first nonactive listening interruption.

METHODS

We analyzed transcripts of 194 adult patients seeking MSK specialty care with a median age (Interquartile range [IQR]) of 47 (33 to 59) years. Participants completed postvisit measures of perceived clinician empathy, symptoms of depression, accommodation of pain, and health anxiety. A nonactive listening interruption was defined as the clinician unilaterally redirecting the topic of conversation. Factors associated with patient-rated clinician empathy, patient problem description duration, and time until the first nonactive listening interruption were sought in bivariate and multivariable analyses.

RESULTS

The patient's narrative was interrupted at least one time in 144 visits (74%). The duration of each visit was a median of 12 minutes (IQR 9 to 16 minutes). The median time patients spent describing their symptoms was 139 seconds before the first interruption (IQR 84 to 225 seconds). The median duration between the end of the initial greeting and the first interruption was 60 seconds (IQR 30 to 103 seconds). Clinician interruption was associated with shorter duration of symptom description. Greater perceived clinician empathy was associated with greater accommodation of pain (regression coefficient [95% confidence interval] = 0.015 [0.0005-0.30]; P = 0.04).

DISCUSSION

Clinician interruption was associated with shorter symptom presentation, but not with diminished perception of clinician empathy. Although active listening and avoidance of interruption are important communication tactics, other aspects of the patient-clinician relationship may have more effect on patient experience.

Recognition, explanation, action, learning: Teaching and delivery of a consultation model for persistent physical symptoms

OBJECTIVE

To describe the teaching and delivery of an extended consultation model designed for clinicians to use with patients with persistent physical symptoms and functional disorders. The model is underpinned by current scientific knowledge about persistent physical symptoms and the communication problems that arise in dealing with them.

METHODS

Process evaluation of training and delivery of the Recognition, Explanation, Action, Learning (REAL) model within the Multiple Symptoms Study 3: a randomised controlled trial of an extended-role GP "Symptoms Clinic". Evaluation used clinician and patient interviews and consultation transcripts.

RESULTS

7 GPs were trained in the intervention and 6 of them went on to deliver the REAL model in Symptoms Clinics either face-to-face or online. The Symptoms Clinic provided a set of 4 extended consultations to approximately 170 patients. Evaluation of training indicated that there was a considerable load in terms of new knowledge and skills. Evaluation of delivery found clinicians could adapt the model to individual patients while maintaining a high level of fidelity to its core components.

CONCLUSION

REAL is a teachable consultation model addressing specific clinical communication issues for people with persistent physical symptoms.

PRACTICE IMPLICATIONS

REAL enables clinicians to explain persistent physical symptoms in a beneficial way.

Treatment-associated network dynamics in patients with globus sensations: a proof-of-concept study

In this proof-of-concept study, we used a systems perspective to conceptualize and investigate treatment-related dynamics (temporal and cross-sectional associations) of symptoms and elements related to the manifestation of a common functional somatic syndrome (FSS), Globus Sensations (GS). We analyzed data from 100 patients (M = 47.1 years, SD = 14.4 years; 64% female) with GS who received eight sessions of group psychotherapy in the context of a randomized controlled trial (RCT). Symptoms and elements were assessed after each treatment session. We applied a multilevel graphical vector-autoregression (ml GVAR) model approach resulting in three separate, complementary networks (temporal, contemporaneous, and between-subject) for an affective, cognitive, and behavioral dimension, respectively. GS were not temporally associated with any affective, cognitive, and behavioral elements. Temporally, catastrophizing cognitions predicted bodily weakness (r = 0.14, p < 0.01, 95% confidence interval (CI) [0.04-0.23]) and GS predicted somatic distress (r = 0.18, p < 0.05, 95% CI [0.04-0.33]). Potential causal pathways between catastrophizing cognitions and bodily weakness as well as GS and somatic distress may reflect treatment-related temporal change processes in patients with GS. Our study illustrates how dynamic NA can be used in the context of outcome research.

Effect of physical activity on long COVID fatigue: an unsolved enigma

Covid-19 disease is well documented and often the most common symptoms include myalgia and muscle fatigue. Approximately 10% of those infected complain of persistent fatigue even many months after the end of the acute phase of the disease. This gives rise to a condition different from the previous one and commonly known as 'post-acute COVID-19 syndrome' or simply Long-COVID. Although the origin of muscle fatigue is multifactorial, the state of prolonged fatigue observed in the Long-COVID syndrome suggests the existence of a possible state of atrophy or rather acute sarcopenia. Under these conditions, the use of physical activity programs can effectively counteract the state of atrophy underlying the fatigue phenomena observed. If this is also the situation during the Long-COVID, the muscular symptom should be positively influenced by the administration of programmed physical activity cycles. In fact, in patients with Long-COVID, the few published papers seem to indicate that patients who are physically active and who make an effort to engage in physical activity even during the illness have decreased duration and intensity of the illness. However, analysis of the studies in the literature also suggests that a small percentage of people with Long-COVID do not appear to benefit from the application of physical activity programs, so further studies on homogeneous samples are needed to provide a firm answer to the question: can planned physical activity help patients during the pathological course of Long-COVID?

Prevalence and correlation of multiple chemical sensitivity and electromagnetic hypersensitivity with age, sex, and depression in the Japanese population: a retrospective study

BACKGROUND

In Japan, there are currently no definitive conclusions regarding the characteristics of multiple chemical sensitivity (MCS) and electromagnetic hypersensitivity (EHS). This study aimed to determine the prevalence and correlation of MCS and EHS with age, sex, and depression in the Japanese population.

METHODS

An anonymous self-report questionnaire was distributed to 2,007 participants. Variables such as MCS, EHS, depression score, and demographic characteristics were individually evaluated using the U-test, chi-squared test, and correlation analyses. Moreover, we performed a covariance structure analysis to build a structural equation model.

RESULTS

Older individuals and women were more likely to exhibit MCS and EHS symptoms. Moreover, depression was correlated with MCS and EHS.

CONCLUSIONS

Although MCS and EHS are strongly correlated, they exhibit distinct characteristics and symptoms, indicating that they can be regarded as separate conditions.

The social representations of diagnosing Lyme disease

Social science studies on the controversy surrounding Lyme disease (LD) focused on the opposition between the "mainstream" and biomedical approach on one side and the "Lyme-literate" one on the other side, the latter claiming the existence of the chronic form of LD. The qualitative and exploratory study 'C18-48 Quali-Explo-PIQTIQ' (2019) investigated the social representations of LD in patients bitten by a tick. Twenty-four semi-structured interviews were conducted in three French medical units. Thematic and patient trajectory analyses were performed. Our results showed that, after the tick bite, some patients presented an "illness without disease" condition, characterised by uncertainty. In some cases, they consulted "Lyme-literate" health providers and received a diagnosis of chronic LD. This diagnosis was obtained by prescribing unassessed biological testing, providing an objective result and clinical categorisation. Unlike literature on the "Lyme-literate" approach, this diagnostic procedure involved some biomedical operations.

Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability

Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.

A randomized controlled trial protocol for persistent physical symptoms associated with indoor environment or chronic fatigue: Effectiveness of video-based functional case conceptualization and web-program for improving quality of life

Introduction

Persistent physical symptoms (PPS) refer to symptoms that cannot be fully explained by structural bodily pathology or by environmental factors. Their impact on daily functioning varies from mild to severe disability. So far, evidence-based treatments for PPS have resulted in only small to moderate effects. Treatment protocols with a stronger orientation toward personalized approaches are needed to improve the efficacy and applicability of treatment. In this study, we aim to assess the effect of an online individual case conceptualization with web-based program for PPS. This study is conducted among two focus groups: patients with indoor air-related symptoms and patients with chronic fatigue syndrome.

Methods and analyses

Using a randomized controlled design (RCT) with two parallel groups in a 1:1 ratio, we will compare individual video-based case conceptualization with a web-based program based on Acceptance and Commitment Therapy (ACT), combined with treatment as usual, with treatment as usual only. The web-based program consists of ten modules, each lasting 1 week and including training. The planned sample size is 124 eligible patients without attrition. The primary outcome will be the health-related quality of life as measured by the 15D questionnaire. The secondary outcome measures will include questionnaires on psychiatric and physical symptoms, illness perceptions, psychological flexibility, and work ability. We will also use national registers to obtain information on the use of healthcare and social benefits to complete patient-reported outcomes. Data collection began in August 2020 and will continue until 2023.

Discussion

This trial will provide information on the effects and usefulness of an online administrated individual case conceptualization and an ACT-based web-program on PPS.

Ethics and dissemination

The Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals.

Clinical Trial Registration

Clinicaltrials.gov, identifier NCT04532827 preresults.

Long COVID: mechanisms, risk factors and recovery

NEW FINDINGS

What is the topic of this review? The emerging condition of long COVID, its epidemiology, pathophysiological impacts on patients of different backgrounds, physiological mechanisms emerging as explanations of the condition, and treatment strategies being trialled. The review leads from a Physiological Society online conference on this topic. What advances does it highlight? Progress in understanding the pathophysiology and cellular mechanisms underlying Long COVID and potential therapeutic and management strategies.

ABSTRACT

Long COVID, the prolonged illness and fatigue suffered by a small proportion of those infected with SARS-CoV-2, is placing an increasing burden on individuals and society. A Physiological Society virtual meeting in February 2022 brought clinicians and researchers together to discuss the current understanding of long COVID mechanisms, risk factors and recovery. This review highlights the themes arising from that meeting. It considers the nature of long COVID, exploring its links with other post-viral illnesses such as myalgic encephalomyelitis/chronic fatigue syndrome, and highlights how long COVID research can help us better support those suffering from all post-viral syndromes. Long COVID research started particularly swiftly in populations routinely monitoring their physical performance - namely the military and elite athletes. The review highlights how the high degree of diagnosis, intervention and monitoring of success in these active populations can suggest management strategies for the wider population. We then consider how a key component of performance monitoring in active populations, cardiopulmonary exercise training, has revealed long COVID-related changes in physiology - including alterations in peripheral muscle function, ventilatory inefficiency and autonomic dysfunction. The nature and impact of dysautonomia are further discussed in relation to postural orthostatic tachycardia syndrome, fatigue and treatment strategies that aim to combat sympathetic overactivation by stimulating the vagus nerve. We then interrogate the mechanisms that underlie long COVID symptoms, with a focus on impaired oxygen delivery due to micro-clotting and disruption of cellular energy metabolism, before considering treatment strategies that indirectly or directly tackle these mechanisms. These include remote inspiratory muscle training and integrated care pathways that combine rehabilitation and drug interventions with research into long COVID healthcare access across different populations. Overall, this review showcases how physiological research reveals the changes that occur in long COVID and how different therapeutic strategies are being developed and tested to combat this condition.

Perceived racial discrimination, psychosomatic symptoms, and resilience among Black individuals in Canada: A moderated mediation model

OBJECTIVE

Although no study has explored psychosomatic symptoms in Black communities in Canada, several studies in the United States showed that psychological distress is often express as physical pain among African Americans. Using a cross-sectional design, the present study documents the frequency of psychosomatic symptoms and its association to racial discrimination, and resilience among Black individuals aged 15 to 40 in Canada.

METHOD

A total of 860 participants (M_age = 25.0 years, SD = 6.3), predominantly born in Canada (79.1%) and women (75.6%), completed the Symptom Checklist-90-Revised (somatization subscale), the Everyday Discrimination Scale, and the Resilience Scale-14.

RESULTS

Findings revealed that 81.7% of participants experienced psychosomatic symptoms, with higher prevalence among women (84.2%) compared to men (70.7%;), ꭓ² = 21.5, p < .001; participants aged 25 to 40 years old (93.7%) compared to those aged 15-24 years old (75.2%) (ꭓ² = 45.0, p < .001). Participants reporting greater racial discrimination had more psychosomatic symptoms (89.4%) compared to others (72.9%), ꭓ² = 39.2, p < .001). A moderated mediation model showed that everyday racial discrimination was positively associated with psychosomatic symptoms (B = 0.1, SE = 0.01, p < .001). The model showed that the association between racial discrimination and psychosomatic symptoms was partially mediated by resilience (B = -0.01, SE = 0.0, p < .01), and negatively moderated by gender (B = -0.04, SE = 0.01, p < .01). In other words, being a woman is associated with higher levels of psychosomatic symptoms among those who have experienced racial discrimination.

CONCLUSION

By highlighting the association between racial discrimination and psychosomatic symptoms and the role of resilience and gender in this relation, this article reveals important factors to integrate to improve healthcare services, prevention, and interventions among Black individuals with psychosomatic symptoms.

Understanding Patient-Provider Interaction, Treatment Acceptance, and Outcomes in Medically Unexplained Symptoms

INTRODUCTION

Medically unexplained symptoms (MUS) is an umbrella term used for chronic and often disabling health symptoms and conditions that remain unexplained after standard medical examinations, testing, and/or appropriate workup. Patients with MUS tend to receive little to no treatment but remain distressed, stigmatized, and disabled by symptoms and iatrogenic factors.

METHODS

A qualitative phenomenological study was conducted to explore daily challenges and psychosocial and iatrogenic factors affecting the management of MUS.

RESULTS

The analysis of the interviews revealed that MUS could cause significant distress to patients, impairing their functioning and leading to permanent disability. Conventional healthcare cannot meet the medical needs of these patients and might be a potential source of harm to them. It should be noted that confirmation of conditions associated with clinically significant psychiatric premorbidity was not provided.

CONCLUSION

Inconsistent diagnostic criteria, lack of proper training and research, diagnostic overshadowing, and implicit bias in healthcare professionals can lead to negative patient outcomes and the overuse of alternative or non-evidence-based services. Guidance, practice-based improvement ideas, and suggestions specific to improving patient-provider relationships can be applied to generate positive health effects.

Risk factors for worsening of somatic symptom burden in a prospective cohort during the COVID-19 pandemic

Introduction

Little is known about risk factors for both Long COVID and somatic symptoms that develop in individuals without a history of COVID-19 in response to the pandemic. There is reason to assume an interplay between pathophysiological mechanisms and psychosocial factors in the etiology of symptom persistence.

Objective

Therefore, this study investigates specific risk factors for somatic symptom deterioration in a cohort of German adults with and without prior SARS-CoV-2 infection.

Methods

German healthcare professionals underwent SARS-CoV-2 IgG antibody testing and completed self-rating questionnaires at baseline and 21 months later between April 2020 and February 2022. Differences in variables between the time points were analyzed and a regression analysis was performed to predict somatic symptom deterioration at follow-up.

Results

Seven hundred fifty-one adults completed both assessments. Until follow-up, n = 58 had contracted SARS-CoV-2 confirmed by serology. Between baseline and follow-up, signs of mental and physical strain increased significantly in the sample. Symptom expectations associated with COVID-19 and a self-reported history of COVID-19, but not serologically confirmed SARS-CoV-2 infection, significantly predicted somatic symptom deterioration at follow-up. A further predictor was baseline psychological symptom burden.

Conclusions

This study supports a disease-overarching biopsychosocial model for the development of burdensome somatic symptoms during the COVID-19 pandemic and supports research findings that symptom burden may be more related to the psychosocial effects of the pandemic than to infection itself. Future studies on Long COVID should include SARS-CoV-2 negative control groups and consider symptom burden prior to infection in order to avoid an overestimation of prevalence rates.

Alexithymia and intolerance of uncertainty predict somatic symptoms in autistic and non-autistic adults

LAY ABSTRACT

Autistic people have more physical health problems than non-autistic people. We were interested in whether autistic people experience more discomfort in their bodies than non-autistic people and whether certain psychological traits contribute to that. A survey was completed online by older adolescents and adults, 51 of whom were autistic, 32 of whom thought they might be autistic but were not diagnosed and 119 who were not autistic. They completed measures of somatic symptoms (daily experience of pain, discomfort, dizziness), alexithymia (difficulty identifying and expressing feelings), interoception (how much people are aware of their bodies) and intolerance of uncertainty (how people handle doubt or uncertainty), and reported any physical or mental health conditions. We found that the autistic participants had more physical and mental health conditions than the non-autistic participants, but even when we took account of this, they experienced higher levels of somatic symptoms. We looked at which psychological factors influenced levels of somatic symptoms across the whole sample, and found that alexithymia, intolerance of uncertainty, having physical health problems, being female and the number of mental health conditions predicted somatic symptoms, while interoception and autism diagnosis did not. The findings suggest that people may be more likely to experience physical discomfort if they are female, and have difficulty identifying and expressing feeling and difficulty tolerating doubt. As these psychological factors are more prominent in autism, we think this is important for physical and mental health providers to know about, so that these psychological factors can be considered when assessing and treating autistic people.

Identifying the top research priorities in medically not yet explained symptoms (MNYES): a James Lind Alliance priority setting partnership

OBJECTIVES

This study establishes research priorities for medically not yet explained symptoms (MNYES), also known as persistent physical symptoms or medically unexplained symptoms, from the perspective of patients, caregivers and clinicians, in a priority setting partnership (PSP) following the James Lind Alliance (JLA) approach. Research into such symptoms in general has been poorly funded over the years and so far has been primarily researcher-led with minimal input from patients, caregivers and clinicians; and sometimes has been controversial.

DESIGN

JLA PSP method. The PSP termed these symptoms MNYES.

METHODS

The study was conducted according to the JLA's detailed methodology for conducting priority setting exercises. It involved five key stages: defining the appropriate term for the conditions under study by the PSP Steering Group; gathering questions on MNYES from patients, caregivers and clinicians in a publicly accessible survey; checking these research questions against existing evidence; interim prioritisation in a second survey; and a final multi-stakeholder consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology.

RESULTS

Over 700 responses from UK patients, caregivers and clinicians were identified in the two surveys and charities contributed from a broad range of medical specialties and primary care. The final top 10 unanswered research questions cover, among others: treatment strategies, personalisation of treatment, collaborative care pathways, training for clinicians and outcomes that matter to patients.

INTERPRETATION

The top 10 unanswered research questions are expected to generate much needed, relevant and impactful research into MNYES.

Multiple symptoms and health anxiety in primary care: a qualitative study of tensions and collaboration between patients and family physicians

BACKGROUND

Patients with multiple, persistent symptoms and health anxiety often report poor health outcomes. Patients who are difficult to reassure are challenging for family physicians. The therapeutic alliance between a physician and a patient can influence the prognosis of these patients. Optimising the quality of the physician-patient alliance may depend on a better understanding of the interpersonal processes that influence this relationship.

OBJECTIVE

The purpose of this study is to understand the experiences of patients who experience multiple persistent symptoms or high health anxiety and their physicians when they interact.

DESIGN, PARTICIPANTS AND SETTING

A qualitative study was conducted using grounded theory of 18 patients, purposively sampled to select patients who reported high physical symptom severity, high health anxiety or both, and 7 family physicians in the same clinic. This study was conducted at a family medicine clinic in a teaching hospital.

RESULTS

A model of interpersonal tension and collaboration for patients and physicians in primary care was developed. Helpful attitudes and actions as well as troublesome topics influence crucial dilemmas between patients and physicians. These dilemmas include if patients feel heard and validated and the alignment of goals and mutual respect of expertise and experience between patients and physicians. These experiences contribute to a constructive collaboration and in turn positive outcomes.

CONCLUSIONS

This model of patient-physician interaction may facilitate providers to turn their attention away from the contentious topics and towards actions and attitudes that promote beneficial outcomes.

The experiences of adolescents diagnosed with functional gastrointestinal disorders: An interpretative phenomenological analysis

The aim of this study was to provide a qualitative perspective of adolescents' experiences of functional gastrointestinal disorders. In-depth semi structured interviews were conducted with eleven adolescents aged 11-16. The transcripts were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: 1) The journey to diagnosis: the good, the bad and the unknown; 2) Making sense of 'functional': the search for meaning; and 3) To share or conceal?: the impact of anticipated stigma on peer disclosure. The themes highlighted a complex process of meaning-making, with limited information about their diagnosis impacting on approaches to self-management and peer disclosure. Findings suggest adolescents would benefit from developmentally appropriate information and resources about the biopsychosocial aetiology of their presentation. It is considered that this may lead to greater self-efficacy in self-management of symptoms and reduce potential for perceived and self-stigma. Further implications for clinical practice and future research are discussed.

Explanatory models of post-traumatic stress disorder (PTSD) and depression among Afghan refugees in Norway

Background

The current situation in Afghanistan makes it likely that we are facing a new wave of Afghan refugees, warranting more knowledge about how to deal with mental health problems among them. This study aims to gain more knowledge on Explanatory Models (EM) of depression and post-traumatic stress disorders (PTSD) among Afghan refugees resettled in Norway.

Methods

We conducted six gender-separated, semi-structured focusgroup interviews based on vignettes with Afghan refugees (total N = 27). The vignettes described a fictional character with symptoms of either depression or PTSD symptoms in line with DSM-5 and ICD-10 criteria.

Results

The findings showed that EM varied with gender, age, generation, and migration stories. Participants suggested different potential causes, risk factors, and ways of managing symptoms of depression and PTSD depending on the context (e.g., in Norway vs. Afghanistan). In describing the causes of the depression/PTSD in the vignettes, females tended to emphasize domestic problems and gender issues while males focused more on acculturation challenges. The younger males discussed mostly traumatic experiences before and during flight as possible causes.

Conclusion

The practice of condensing a single set of EMs within a group may not only be analytically challenging in a time-pressed clinical setting but also misleading. Rather, we advocate asking empathic questions and roughly mapping individual refugee patients’ perceptions on causes and treatment as a better starting point for building trusting relationships and inviting patients to share and put into practice their expertise about their own lives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00709-0.

"This Might Be Your New Normal…" Storytelling Amidst Uncertainty and Medically Unexplained Symptoms

The medical diagnostic journey can be filled with uncertainty, anxiety, tension, and complications. This essay moves between first-person storytelling and analytic memos to illustrate defining moments of a diagnostic journey. It brings to life the complexity of navigating the healthcare system through the eyes of someone with medically unexplained symptoms (MUS). Additionally, it presses into the complex nature of the medical world and how one communicates through those tensions with healthcare professionals, loved ones, and colleagues when their illness is questioned and doubted.

Childhood adversity and attachment anxiety predict adult symptom severity and health anxiety

BACKGROUND

Childhood adversity is associated with somatization, including physical symptom burden and health anxiety. Attachment theory offers a developmental framework to understand adult somatization, as attachment phenomena are theoretically and empirically related to physiological regulation, affect regulation, and childhood adversity, all of which are relevant to somatization.

OBJECTIVE

The purpose of this study was to identify the pathways by which childhood adversity and attachment insecurity influence physical symptom burden and health anxiety in adults.

PARTICIPANTS AND SETTING

Three hundred and fifty-one family medicine patients from a teaching hospital in Toronto, Canada.

METHODS

A cross-sectional survey study was conducted to assess adverse childhood experiences, attachment insecurity, health anxiety and physical symptom severity in primary care patients. Path Analysis using structural equation modeling (AMOS V.26, IBM, 2019) was used to test the model in which childhood adversity, attachment anxiety, attachment avoidance, symptom severity interact to influence health anxiety.

RESULTS

The majority of the participants were white (66%), had completed post-secondary education (68%), and reported themselves to be in very good to excellent health (62%). Childhood adversity, attachment anxiety, attachment avoidance, health anxiety and symptom severity are all significantly correlated (ranges of r_s = 0.29 to 0.63). Childhood adversity has a significant indirect effect on health anxiety with attachment anxiety and symptom severity as serial mediators (β_indirect = 0.237, p = .001 and β_direct = 0.065, p = .244).

CONCLUSIONS

Overall, this model extends our understanding of the processes underlying adult somatization. Findings support that childhood adversity and attachment anxiety are predictors of symptom severity and health anxiety.

Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress

This paper argues that “functional,” “medically unexplained,” or “somatoform” symptoms and disorders necessarily require a patient-centered approach from the clinicians. In the first part, I address the multiple causes of the patients' suffering and I analyze the unease of the doctors faced with these disorders. I emphasize the iatrogenic role of medical investigations and the frequent failure in attempting to reassure the patients. I stress the difficulties in finding the right terms and concepts, despite overabundant nosological categories, to give a full account of psychosomatic complexity. Finally, I discuss the moral dimension attached to assigning a symptom, at times arbitrarily, to a psychogenic origin. The following part presents a brief reminder of the patient-centered approach (PCA) in medicine. In the last part, I aim to explain why and how patient-centered medicine should be applied in the context of functional disorders. First, because PCA focuses on the patients' experience of illness rather than the disease from the medical point of view, which is, indeed, absent. Second, because PCA is the only way to avoid sterile attribution conflicts. Last, because PCA allows doctors and patients to collaboratively create plausible and non-stigmatizing explanations for the symptoms, which paves the way toward effective management.

The 6C model for accurately capturing the patient's medical history

Diagnostic errors are an internationally recognized patient safety concern, and leading causes are faulty data gathering and faulty information processing. Obtaining a full and accurate history from the patient is the foundation for timely and accurate diagnosis. A key concept underlying ideal history acquisition is "history clarification," meaning that the history is clarified to be depicted as clearly as a video, with the chronology being accurately reproduced. A novel approach is presented to improve history-taking, involving six dimensions: Courtesy, Control, Compassion, Curiosity, Clear mind, and Concentration, the '6 C's'. We report a case that illustrates how the 6C approach can improve diagnosis, especially in relation to artificial intelligence tools that assist with differential diagnosis.

Explanatory models and help-seeking for symptoms of PTSD and depression among Syrian refugees

OBJECTIVE

This study investigates how Syrian refugees explain and prefer to seek help for symptoms of post-traumatic stress disorder (PTSD) and depression.

METHODS

We conducted five semi-structured focus group interviews based on a vignette-technique with Syrian refugees (n = 21 men, n = 10 women). The vignettes describe a fictional person suffering from symptoms of PTSD or depression in line with DSM-5 and ICD-10 criteria.

RESULTS

Despite never mentioning PTSD, participants in the PTSD-interviews recognized the symptoms. They perceived them as a common reaction to extreme situations, mainly the war, the flight, and post-migratory stressors. Depression was labeled as either depression or feelings caused by social problems, and the participants were more hesitant to identify with these symptoms. Despite some differences, both the PTSD and depression vignettes were explained in terms of situational explanatory models and externally caused stress. The main finding is how participants described changing stressors resulting from migration and resettlement leading to a difference in how they would seek help in Syria and in Norway. Specifically, we found that preferred help-seeking and coping strategies are contextual.

CONCLUSIONS

These findings point to the need to consider transformations following forced migration when studying aspects of explanatory models, preferred help-seeking, and coping strategies in refugee groups.

Complex PTSD symptoms mediate the association between childhood trauma and physical health problems

The ICD-11 reconceptualized Posttraumatic Stress Disorder (PTSD) as a narrowly defined fear-based disorder, and introduced Complex PTSD (CPTSD) as a new diagnosis comprised of PTSD symptoms and symptoms of 'Disturbances in Self-Organization' (DSO) that are more reflective of general dysphoria. Previous research suggests that PTSD symptoms mediate the association between childhood trauma and physical health problems, including cardiovascular disease. No study has yet assessed how posttraumatic stress symptoms, as outlined in the ICD-11, influence the association between childhood trauma and somatic problems in adulthood.

OBJECTIVE

This cross-sectional descriptive study examined whether PTSD and DSO symptoms mediated the associations between childhood physical and sexual abuse and childhood emotional abuse and neglect and somatic problems and cardiovascular diseases (CVD) load in adulthood.

METHODS

General adult population samples from Ireland (N = 1020) and the United Kingdom (N = 1051) completed self-report questionnaires online.

RESULTS

Structural equation modelling results indicated that PTSD and DSO symptoms fully mediated the association between both forms of childhood trauma and somatic problems, and that PTSD symptoms but not DSO symptoms fully mediated the association between childhood trauma and CVD load.

CONCLUSION

Psychological interventions that effectively treat CPTSD symptoms may have the added benefit of reducing risk of physical health problems.

Somatic symptoms of helplessness and hopelessness

Helplessness and hopelessness are transdiagnostic and aggravating factors of mental ill health, but their relation with somatization is not well documented. The main objectives were to identify somatic symptoms that are particularly associated with helplessness, referred to as somatic symptoms of helplessness (SS-He), and hopelessness, referred to as somatic symptoms of hopelessness (SS-Ho), determine increased risk of helplessness and hopelessness if having these symptoms and a certain number of these symptoms, and determine sensitivity and specificity in identifying helplessness and hopelessness based on number of these symptoms in a general Swedish sample. Population-based data from validated questionnaire instruments were used from 3,210 participants who constituted case groups of helplessness and hopelessness, and corresponding reference groups. Among 15 common somatic symptoms, five SS-He (e.g., feeling tired/having low energy) and five SS-Ho (e.g., dizziness) were identified, showing increased risk of helplessness and hopelessness that ranged from the factor 1.73 to 2.58 and from 1.44 to 1.92, respectively, which decreased considerably when controlled for depression and anxiety. The risk of helplessness increased by the factor 1.49 for each additional SS-He, and by 1.38 for each SS-Ho. A cutoff of two/three or more SS-He showed a sensitivity of 81.7/63.7% and a specificity of 40.6/61.4% in identifying helplessness, and 77.4/54.6% and 40.4/66.1%, respectively, in identifying hopelessness based on two/three or more SS-Ho. Primary care clinicians may consider further investigation of helplessness and hopelessness as well as depression and anxiety if presenting with these symptoms.

Structural validation of The Patient Health Questionnaire-9 (PHQ-9) among Filipina and Indonesian female migrant domestic workers in Macao: STRUCTURAL VALIDATION OF PHQ-9

Within diverse global populations, validated tools are needed to assess common mental disorders. The Patient Health Questionnaire-9 (PHQ-9) is one of the most commonly used depression screeners. However, the PHQ-9 has not been structurally validated among female migrant domestic workers (MDWs). Female MDWs constitute a population numbering 11.5 million, and commonly report depression. This study aimed to structurally validate the PHQ-9 among Filipina and Indonesian female MDWs in Macao Special Administrative Region of China. Participants were recruited using respondent driven sampling. Participants were adult female MDWs from The Philippines (N=1375) or Indonesia (N=367) and legally working in Macao. We used confirmatory factor analysis (CFA) to test five structural models of depression using all PHQ-9 items with the Filipina and Indonesian samples. We applied multi-group CFA to test measurement invariance across samples. A two-factor (cognitive/affective, somatic) model yielded the best fit within both samples, and the multi-group CFA demonstrated invariance across samples. The two-factor model best represents the factor structure of the PHQ-9 among Filipina and Indonesian female MDWs.

Reduced Heart Rate Variability in Patients With Medically Unexplained Physical Symptoms: A Meta-Analysis of HF-HRV and RMSSD

OBJECTIVE

Medically unexplained physical symptoms (MUPS) and related syndromes are common and place a substantial burden on both patients and society. Chronic psychological distress and dysregulation of the autonomic nervous system may be common factors associated with MUPS, although previous studies have reported mixed results. The aims of this meta-analysis are to provide an updated synthesis of studies investigating heart rate variability (HRV) indices associated with autonomic nervous system functioning in three common MUPS syndromes and to explain inconsistencies in previous study findings.

METHODS

Literature search yielded 58 studies comparing HRV indices of reduced parasympathetic activity of healthy individuals with those of patients with chronic fatigue syndrome (npatients = 271), irritable bowel syndrome (npatients = 1005), and fibromyalgia (npatients = 534). Separate random-effects meta-analyses were conducted on studies measuring root mean square of successive differences (RMSSD) and high-frequency HRV (HF-HRV).

RESULTS

Regardless of syndrome type, patients had significantly lower RMSSD (k = 22, Hedges g = -0.37 [-0.53 to -0.21], p < .001) and HF-HRV (k = 52, Hedges g = -0.69 [-1.03 to -0.36], p < .001) than did healthy individuals. Sample age and publication year explained a substantial variation in RMSSD, whereas controlling for confounders in statistical analyses explained variation in HF-HRV.

CONCLUSIONS

Lower RMSSD and HF-HRV in patients with MUPS versus healthy controls indicates that autonomic nervous system dysregulation, particularly lower parasympathetic activity, may play a role in patients with these conditions. This conclusion may have important implications for the underlying mechanisms and treatment of MUPS and related syndromes.

A Qualitative Study of the Views of Patients With Medically Unexplained Symptoms on The BodyMind Approach®: Employing Embodied Methods and Arts Practices for Self-Management

The arts provide openings for symbolic expression by engaging the sensory experience in the body they become a source of insight through embodied cognition and emotion, enabling meaning-making, and acting as a catalyst for change. This synthesis of sensation and enactive, embodied expression through movement and the arts is capitalized on in The BodyMind Approach^® (TBMA). It is integral to this biopsychosocial, innovative, unique intervention for people suffering medically unexplained symptoms (MUS) applied in primary healthcare. The relevance of embodiment and arts practices in TBMA are discussed in relation to the views of participants in the pursuit of self-management. If widely employed TBMA could have an enormous impact, reach, and significance for patients and global health services. This original pre-clinical trial of qualitative research reports on the perceptions of participant patients with generic MUS, a world-wide issue usually treated by either psychological therapy or physiotherapy. TBMA is not a therapy but a health education program founded upon the concept of an integration of psychological elements with physiological, bodily, and sensory experiences. Thematic analysis of qualitative data sets from open-ended questions in semi-structured interviews and a written questionnaire post intervention is presented. Five aspects which appear to be key to learning self-management were derived from analyzing the data: (1) body with mind connections; (2) importance of facilitation; (3) potential benefits; (4) preparedness for change; (5) self-acceptance/compassion. This article advances the discourse on the nature of self-management for MUS through changing the mind-set and the relationship participants have with their bodily symptom/s through employing embodied methods and arts practices, challenging current, and solely verbal, psychological conceptual frameworks. Rigor lies in the method of data analysis using cross verification of credibility between reported findings and scrutiny by stakeholders. We conclude that facilitated TBMA groups employing embodied methods and arts practices can act as a method for developing the self-management of MUS and improving wellbeing.

Clinical presentations on a facial pain clinic

Introduction The complex nature of facial pain conditions creates a diagnostic challenge which may necessitate specialist referral.Aim To identify the case mix presenting to a specialist tertiary care facial pain clinic.Methods A retrospective review of 112 patient records was undertaken. Trends in provisional diagnoses from referrers and the correlation to diagnoses made following specialist consultation were reviewed.Results The most common provisional diagnoses recorded in referral letters were painful temporomandibular disorders, trigeminal neuralgia and persistent idiopathic facial pain (PIFP). Over a quarter of referrals did not include a provisional diagnosis. Following assessment, only one case was not given a definitive diagnosis and no patients were diagnosed with PIFP. A causative factor was identified in all the initially queried PIFP cases, and painful post-traumatic trigeminal neuropathic pain was found in multiple patients.Conclusions Painful post-traumatic trigeminal neuropathic pain should be considered if pain onset coincides with dental treatment or other traumatic events. PIFP is a rare facial pain diagnosis and may be over-diagnosed by dental and medical practitioners. It is important to systematically exclude other causes before reaching this diagnosis. This will facilitate effective treatment, manage patient expectations and potentially reduce unnecessary referrals.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

BACKGROUND

The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms.

OBJECTIVES

An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis.

DATA SOURCES

Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019.

PARTICIPANTS

Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes.

INTERVENTIONS

Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes.

RESULTS

Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000.

LIMITATIONS

Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points.

CONCLUSIONS

Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study).

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015025520.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.

Improving the accuracy of medical diagnosis with causal machine learning

Machine learning promises to revolutionize clinical decision making and diagnosis. In medical diagnosis a doctor aims to explain a patient's symptoms by determining the diseases causing them. However, existing machine learning approaches to diagnosis are purely associative, identifying diseases that are strongly correlated with a patients symptoms. We show that this inability to disentangle correlation from causation can result in sub-optimal or dangerous diagnoses. To overcome this, we reformulate diagnosis as a counterfactual inference task and derive counterfactual diagnostic algorithms. We compare our counterfactual algorithms to the standard associative algorithm and 44 doctors using a test set of clinical vignettes. While the associative algorithm achieves an accuracy placing in the top 48% of doctors in our cohort, our counterfactual algorithm places in the top 25% of doctors, achieving expert clinical accuracy. Our results show that causal reasoning is a vital missing ingredient for applying machine learning to medical diagnosis.

A Cross-Sectional Study on Central Sensitization and Autonomic Changes in Fibromyalgia

Fibromyalgia is a multi-symptomatic disorder characterized by generalized pain. The pathophysiology of fibromyalgia is supposedly an interplay between central nervous system hyper-responsiveness, autonomic dysfunction, and peripheral pain. In this cross-sectional study, the objective was to assess central sensitization and autonomic activity in patients with fibromyalgia compared with control. Fifty adults diagnosed with fibromyalgia by the modified American College of Rheumatology 2010 criteria and an equal number of age- and sex-matched controls participated in the study in an urban tertiary care hospital. Central sensitization was assessed by history and by evidence of increased prefrontal cortical activity as measured by cortical oxygenation using functional near-infrared spectroscopy. Autonomic activity was assessed by heart rate variability, electrodermal activity, and deep breathing test in three physiological states: rest, sympathetic stress (cold pressor test), and deep breathing. Mann–Whitney U-test, paired t-test, Wilcoxon test, and Friedman test with Bonferroni a priori were used to analyze the data. Cortical activity was significantly higher in the fibromyalgia group than control. There was no significant difference in autonomic activity between the fibromyalgia and control groups. In the fibromyalgia group, variable degrees of sympathetic hyperactivity and normal parasympathetic activity were observed. Central sensitization may be playing a primary role in the pathophysiology of generalized pain in fibromyalgia.

'Fixing my life': young people's everyday efforts towards recovery from persistent bodily complaints

Little is known about the perspectives of young people suffering from medically unexplained symptoms. This study aims to explore the experiences and strategies of young Norwegians related to incipient and persistent health complaints affecting everyday life functioning. The study draws on field notes, video material and interview transcripts from a multi-sited ethnographic study of healthcare services and select schools in a small Norwegian town between 2015 and 2016. A central theme is the emphasis upon social and existential constraints seemingly framed by a social imaginary of youth rather than a medical imaginary, and their active engagements to 'fix' their lives through what we identify as two main modalities of self-care. Navigating temporal and relational aspects of sociocultural configurations of youth in their social environments, they imagine and enact alternative qualifying positions better adapted to constraints, personal preferences and needs. Our findings may add to understandings of the needs and strategies of young sufferers of medically unexplained symptoms, relevant for health and social care encounters.

Engaging patients with "medically unexplained symptoms" in psychological therapy: An integrative and transdiagnostic approach

OBJECTIVES

Patients with "medically unexplained symptoms" or "MUS" experience subjectively compelling and distressing somatic symptoms that are not fully explained by underlying physical pathology. Effective treatment of these patients has been impeded by multiple barriers. Problems with patient engagement have been highlighted in the clinical and research literature, yet few exploratory studies have been conducted in this area. This research explores how experienced psychological therapists in a specialist MUS service work to engage these patients.

DESIGN

An in-depth qualitative study was conducted to explore the process of engaging patients with MUS in psychological therapy.

METHOD

Semi-structured depth interviews were conducted with psychological therapists who work with complex patients with MUS. The therapists interviewed were recruited from an NHS primary care psychological therapy service that specializes in working with this patient group. Data were analysed using grounded theory to develop a model of this process.

RESULTS

The analysis identified how multiple interacting layers of systemic, interpersonal, and intrapsychic disconnections impede engagement. The research introduces a new theoretical framework 'Negotiating disconnection' that conceptualizes the process of engagement in terms of a series of stages, namely 'Drawing in' (negotiating systemic disconnection), 'Meeting' (connecting in the disconnection), and 'Nudging Forward' (cultivating new connections), and illustrates how these are negotiated by therapists.

CONCLUSIONS

The model shows that it is critical for therapists to collaborate closely with GPs to engage these patients while also highlighting barriers to doing this, reflecting the complexities of organizational and cultural change. Clinically, the model illustrates the importance of adopting a flexible, pluralistic, and integrative approach that is person-centred and process-led. Doctors and therapists should embrace a holistic, biopsychosocial stance towards MUS and be sensitively attuned to its complex phenomenology.

PRACTITIONER POINTS

To engage patients with MUS psychological therapists should be person-centred and process-led rather than theory- or protocol-led. A pluralistic and integrative mindset facilitates this by enhancing clinicians' flexibility. A multidisciplinary approach is essential. Clinicians should embrace a biopsychosocial stance towards MUS and work closely with medical colleagues to help them do the same. Structural and cultural change is needed to tackle this issue effectively.

Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review

OBJECTIVE

The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research.

METHODS

A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity.

RESULTS

We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions.

CONCLUSIONS

Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.

Cultural competency training in psychiatry

Recent reports indicate that the quality of care provided to immigrant and ethnic minority patients is not at the same level as that provided to majority group patients. Although the European Board of Medical Specialists recognizes awareness of cultural issues as a core component of the psychiatry specialization, few medical schools provide training in cultural issues. Cultural competence represents a comprehensive response to the mental health care needs of immigrant and ethnic minority patients. Cultural competence training involves the development of knowledge, skills, and attitudes that can improve the effectiveness of psychiatric treatment. Cognitive cultural competence involves awareness of the various ways in which culture, immigration status, and race impact psychosocial development, psychopathology, and therapeutic transactions. Technical cultural competence involves the application of cognitive cultural competence, and requires proficiency in intercultural communication, the capacity to develop a therapeutic relationship with a culturally different patient, and the ability to adapt diagnosis and treatment in response to cultural difference. Perhaps the greatest challenge in cultural competence training involves the development of attitudinal competence inasmuch as it requires exploration of cultural and racial preconceptions. Although research is in its infancy, there are increasing indications that cultural competence can improve key aspects of the psychiatric treatment of immigrant and minority group patients.

Explanations for medically unexplained symptoms: a qualitative study on GPs in daily practice consultations

BACKGROUND

General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice.

OBJECTIVE

This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations.

METHODS

A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS.

RESULTS

GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed.

CONCLUSION

Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice.

Social Factors of Health-Seeking Behavior: On Medical Treatment for Elders With Dementia in Oaxaca, Mexico

This article presents data on family caregiving for elders with dementia in Oaxaca, Mexico. Drawing on a year of ethnographic research, this article explores how caregivers engage in health-seeking behaviors and how they choose between biomedical and traditional medical alternatives. While caregivers are primarily concerned to maintain elders’ health, decisions about which medical providers to (not) consult invoke broader social factors that go beyond their relationships with elders, and concern socioeconomic realms of power, as well as broader ideals concerning local tradition and its maintenance in the contemporary world.