The shadow of dementia: Listening to undecidability in ethnographic interviews with persons suspecting possible dementia

Even before a diagnosis of dementia, people may negotiate in their everyday lives the fears and suspicions about the possibility of a future with dementia. My field of research involves JewishIsraeli older adult individuals who suspect that they are beginning to lose their memory, but before seeking out a formal diagnosis-and when not seeking a diagnosis at all is an equal possibility. By distinguishing their experience of suspecting possible dementia from this of living with dementia, I attempt to illuminate the social, bio-diagnostic and cultural shadows of dementia hovering in the background of their everyday experience. I begin by shedding light on the ethical and methodological context of my specific field in Israel. I next reflect upon the concept of "shadow," that is constituted within and reflecting the assemblages of lurking presences accompanying my interlocutors' daily negotiations of the possibility of dementia. I then situate their lived experiences, as well as my ethnographic engagement with them, in the context of the prevailing cultural and social moralities surrounding this possibility. Finally, I show how a negotiation of the place that this shadow occupies in their lives arises in the encounter with the ethnographer. This first account of people before diagnosis and not through the diagnostic event, while keeping the space for deciding about a possible future of diagnosis open, can contribute to the understanding of undecidability as an ethical stance in ethnography, incorporating the suspension of the need to order realities through the imperatives of a diagnosis of dementia. Further, understanding these mundane negotiations with these shadows can help us allow more space for uncertainty and unpredictability as legitimate forms of living with dementia.

Do we know the mind of others? Suspicion of malingering in emergency psychiatry

INTRODUCTION

Malingering can be divided into simulation and exaggeration of symptoms. Malingering has traditionally been considered rare in general psychiatry. In contrast to earlier estimates, more recent studies report that doctors suspect malingering frequently in psychiatric emergency departments. The aim of this study is to survey how often doctors in psychiatric emergency units in a public, free-of-charge, mental health service suspect that patients are malingering, and which diagnoses, symptom complaints and suspected reasons for malingering doctors ascribe to their patients.

METHODS

Questionnaires were distributed in three psychiatric emergency departments in Denmark. Suspected simulation and exaggeration were rated with a 5-point scale. Doctors were encouraged to write down the symptoms and perceived causes for suspected malingering.

RESULTS

362 questionnaires were filled in. 25% of all patients were suspected of simulating to some degree. 8% of patients were highly suspected or definitely believed to be simulating. Patients complaining of suicidal ideation were most frequently suspected of malingering. 'Attention seeking' was the most common suspected reason for malingering. Patients with diagnoses of substance use and personality disorder were the most suspected of malingering.

CONCLUSION

This is the first study to investigate doctors' suspicions of psychiatric malingering in a European setting. Patients with established personality and substance use disorder are at higher risk of being suspected of malingering, which potentially affects the course of treatment significantly. The rise in suspected malingering is conspicuous and requires further investigation. Doctors are encouraged to act conservatively upon suspicion of malingering in emergency psychiatry.

Explaining consumer suspicion: insights of a vignette study on online product reviews

As part of the online product and service selection and purchase process, many consumers consult and rely on online product reviews. In order to persuade potential customers to buy their products, many organizations and businesses post deceptive product reviews of their own products on their own or third-party websites to their advantage. This creates consumer suspicion about the authenticity and veracity of online product reviews. To better understand how consumers' experiences of having been deceived by deceptive online product reviews in the past and the density of deception characteristics in an online product review influence their level of suspicion about the review and, ultimately, their intention to buy the product, we conduct a 3 × 3 vignette study. Our results indicate that deceptive characteristics in online product reviews and prior encounters with deception in online marketplaces increase consumer suspicion. Furthermore, we show that preference for a specific product decreases consumer suspicion about reviews of that product. Lastly, we demonstrate that consumer suspicion towards a product decreases purchase intention.

Suspicion, screening, and diagnosis of wild-type transthyretin amyloid cardiomyopathy: a systematic literature review

Wild-type transthyretin amyloid cardiomyopathy (ATTRwt CM) is a more common disease than previously thought. Awareness of ATTRwt CM and its diagnosis has been challenged by its unspecific and widely distributed clinical manifestations and traditionally invasive diagnostic tools. Recent advances in echocardiography and cardiac magnetic resonance (CMR), non-invasive diagnosis by bone scintigraphy, and the development of disease-modifying treatments have resulted in an increased interest, reflected in multiple publications especially during the last decade. To get an overview of the scientific knowledge and gaps related to patient entry, suspicion, diagnosis, and systematic screening of ATTRwt CM, we developed a framework to systematically map the available evidence of (i) when to suspect ATTRwt CM in a patient, (ii) how to diagnose the disease, and (iii) which at-risk populations to screen for ATTRwt CM. Articles published between 2010 and August 2021 containing part of or a full diagnostic pathway for ATTRwt CM were included. From these articles, data for patient entry, suspicion, diagnosis, and screening were extracted, as were key study design and results from the original studies referred to. A total of 50 articles met the inclusion criteria. Of these, five were position statements from academic societies, while one was a clinical guideline. Three articles discussed the importance of primary care providers in terms of patient entry, while the remaining articles had the cardiovascular setting as point of departure. The most frequently mentioned suspicion criteria were ventricular wall thickening (44/50), carpal tunnel syndrome (42/50), and late gadolinium enhancement on CMR (43/50). Diagnostic pathways varied slightly, but most included bone scintigraphy, exclusion of light-chain amyloidosis, and the possibility of doing a biopsy. Systematic screening was mentioned in 16 articles, 10 of which suggested specific at-risk populations for screening. The European Society of Cardiology recommends to screen patients with a wall thickness ≥12 mm and heart failure, aortic stenosis, or red flag symptoms, especially if they are >65 years. The underlying evidence was generally good for diagnosis, while significant gaps were identified for the relevance and mutual ranking of the different suspicion criteria and for systematic screening. Conclusively, patient entry was neglected in the reviewed literature. While multiple red flags were described, high-quality prospective studies designed to evaluate their suitability as suspicion criteria were lacking. An upcoming task lies in defining and evaluating at-risk populations for screening. All are steps needed to promote early detection and diagnosis of ATTRwt CM, a prerequisite for timely treatment.

Contested notions of challenges affecting Community Health Workers in low- and middle-income countries informed by the Silences Framework

Despite increasing evidence of the challenges affecting Community Health Workers (CHWs) such as those related to training, supportive supervision and remuneration, there is a need to explore concerns and challenges from the perspective of CHWs themselves. This commentary highlights some of the contested and unexplored notions of challenges affecting CHWs in low- and middle-income countries (LMICs) informed by the Silences Framework. This framework defines experiences that are under-explored, misunderstood or difficult to share because of the often invisible power relations within communities, but also in setting the research agenda. These challenges include the heavy workload imposed by several stakeholders, dealing with religious and cultural practices, and gendered barriers of care. The workload of CHWs is a major source of stress and anxiety as they have to balance both government and other stakeholders' agendas to deliver interventions with their own need to provide for their families for those whose work is unpaid. The tensions of CHWs carrying out their work among members of the community whose religious or cultural beliefs are different from theirs also needs to be considered. Gender issues are an impediment to the work of CHWs, particularly with community members of the opposite sex around sensitive health issues. Lastly, CHWs have found themselves victims of domestic suspicion while fulfilling their duties in communities, such as when seen having conversations with spouses of other individuals in the community. Solutions to these challenges need to be co-produced with CHWs to both to strengthen their relationship with the communities they serve and shape more sustainable interventions for delivery of healthcare in LMICs.