Talking at cross purposes: Negotiation of the sick role with a MUS patient as a real time social process

Medically unexplained symptoms (MUS) challenge our perception of illness. As a consequence, a MUS-patient’s legitimised entry into the sick role, as defined by Parsons, poses a problem for physicians and patients alike. The encounter between patients with MUS and physicians therefore can be frustrating for both parties. The present study is a single case analysis of such an encounter in primary care. Using the microanalytical method of conversation analysis, this study aims to provide a contextualised description of both the patient’s and the physician’s different orientations to the purpose of the encounter. This approach locates the source of the frustration in the participants’ incompatible interactional projects. The patient is oriented towards the emotional and life world aspects of her situation. She is pursuing recognition, not only of the destructive effect that the symptoms have on all aspects of her life, but also of herself as a morally sound person. The physician, on the contrary, is oriented towards avoiding to psychologise the patient and keeping the focus on reaching an agreement about future clinical action. The physician uses ancillary questions to refocus the emotionally loaded contributions from the patient and maintain structured progression. Consequently, physician and patient are talking at cross purposes, and it is argued that this is a structurally facilitated pitfall of the conventional format of primary care visits that physicians are trained to adhere to

Can the bodily distress syndrome (BDS) concept be used to assess functional somatic symptoms in adolescence?

Objective: Bodily Distress Syndrome (BDS) represents a new research concept for adult patients with various functional somatic syndromes. We evaluated the utility of the BDS research concept and the associated BDS-25-checklist as a screening tool for diverse functional somatic symptoms (FSS) in adolescence by investigating: 1) the psychometric and factorial structures of the checklist, 2) symptom cluster patterns and 3) illness classification and associations with emotional psychopathology and sociodemographic factors. Methods: This cross-sectional study obtained data from the 16/17-year follow-up (N = 2542) of the general population Copenhagen Child Cohort 2000 (CCC2000). We used self-reported questionnaires to assess physical symptoms (the BDS-25 checklist), overall health (KidScreen), emotional psychopathology (Spence Children's Anxiety Scale; The Mood and Feelings Questionnaire), and illness worry (Whiteley-6 Index), and utilized data from Danish national registers to assess sociodemographic factors. Results: The BDS-25 checklist items displayed satisfactory psychometric data quality. Factor analyses revealed a similar four-factor model as reported in adults (factor loadings λ ≥0.5), representing distinct BDS symptom clusters: cardio-pulmonary, gastro-intestinal, musculoskeletal and general symptoms. Latent class analyses revealed a model with three latent classes, i.e. probable no to mild BDS, probable moderate, single-organ BDS and probable severe, multi-organ BDS, displaying acceptable class quality (Entropy = 0.904). Trend analyses revealed sociodemographic group differences across latent classes. Increased emotional psychopathology was associated with more pronounced BDS symptoms. Conclusion: Our findings support the BDS concept with four symptom clusters and three illness severity groups (no BDS, single- organ and multi-organ BDS) to screen for FSS in adolescence

A European research agenda for somatic symptom disorders, bodily distress disorders, and functional disorders: Results of an estimate-talk-estimate delphi expert study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe

Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study

Background: Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions. Methods: International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken. Results: Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%–88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%–92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD. Conclusions: Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions

Sygdomsopfattelse - et sundhedspsykologisk perspektiv

I det følgende vil jeg præsentere en kognitionspsykologisk model af sygdomsopfattelse. Med udgangspunkt i en undersøgelse, jeg foretog hos 38 praktiserende læger og 1785 patienter i Århus Amt år 2002-20021, undersøges, om denne model er anvendelig i almen praksis, og om patienter med funktionelle fysiske symptomer (FSS) i deres sygdomsopfattelse adskiller sig fra andre patientgrupper i almen praksis

Initial healthcare and coping preferences are associated with outcome 1 year after whiplash trauma: A multicentre 1-year follow-up study

Objective: Individuals exposed to whiplash collisions have to cope with the stressful event as well as early physical symptoms. As in other chronic pain conditions, coping has been associated with outcome after whiplash. In this study, our aim was to examine whether initial coping preferences were associated with the development of chronic whiplash. Design: Prospective study. Setting: Primary care. Methods: 740 acute whiplash patients were recruited from emergency units and general practitioners after car collisions in Denmark. Within 10 days postinjury, participants were asked what they believed could help them get better. At 12-month follow-up, the level of neck pain and capability to work was obtained. Whether coping preferences (baseline) were associated with outcome was investigated using multiple regression analyses. Results: Persistent neck pain was most strongly associated with preferring medications (mean difference=1.24 (95% CI 0.67 to 1.82)) and sickness absence (mean difference=1.18 (95% CI 0.53 to 1.82)). Reduced work capability was most strongly associated with preferring medications (OR=3.53 (95% CI 2.13 to 5.86)), sickness absence (OR=3.05 (95% CI 1.80 to 5.17)) and being referred to a physiotherapist/chiropractor (OR=3.03 (95% CI 1.33 to 6.91)). Active coping was associated with better outcomes: Participants preferring to change their lifestyle were protected against reduced work capability (OR=0.11 (95% CI 0.01 to 0.78)). Individuals who wanted to keep living as usual only (no other preference reported) were protected against neck pain (mean difference −1.62 (95% CI −2.39 to −0.84)) and reduced work capability (OR=0.09 (95% CI 0.01 to 0.64)). Conclusions: A simple nine-item measure of coping preferences is associated with the development of chronic neck pain and reduced capability to work following whiplash trauma and may be used to identify individuals at risk of poor recovery

Development of an Internet-delivered educational video for acute whiplash injuries

Abstract Objective To describe the development of a preventive educational video for patients exposed to whiplash trauma following motor vehicle accidents. Methods The development followed a systematic approach and was theory-driven supplemented with available empirical knowledge. The specific content was developed by a multidisciplinary group involving health professionals and visual production specialists. Results A 14-min educational video was created. The video content focuses on stimulating adaptive recovery expectations and preventing maladaptive illness beliefs. The video presents a multifactorial model for pain incorporating physiological and cognitive-behavioural aspects, advice on pain relief, and exercises. Subjects interviewed for a qualitative evaluation found the video reassuring and that it aligned well with verbal information received in the hospital. Conclusions The development of the visual educational intervention benefitted from a systematic development approach entailing both theoretical and research-based knowledge. The sparse evidence on educational information for acute whiplash trauma posed a challenge for creating content. Further knowledge is required regarding what assists recovery in the early stages of whiplash injuries in order to improve the development of educational interventions