Concordance of Illness Representations: The Key to Improving Care of Medically Unexplained Symptoms

How can effective patient-provider relationships be developed when the underlying cause of the health condition is not well understood and becomes a point of controversy between patient and provider? This problem underlies the difficulty in treating medically unexplained symptoms and syndromes (MUS; e.g., fibromyalgia, chronic fatigue syndrome), which primary care providers consider to be among the most difficult conditions to treat.1 This difficulty extends to the patient-provider relationship which is characterized by discord over MUS.1 In this article, we argue that the key to improving the patient provider relationship is for the patient and provider to develop congruent illness perceptions about MUS

The Common Sense of Counseling Psychology: Introducing

The goal of therapy is typically to improve clients’ self-management of their problems, not only during the course of therapy but also after therapy ends. Although it seems obvious that therapists are interested in improving client’s self-management, the psychotherapy literature has little to say on the topic. This article introduces Leventhal’s Common-Sense Model of Self-Regulation, a theoretical model of the self-management of health, and applies the model to the therapeutic process. The Common-Sense Model proposes that people develop illness representations of health threats and these illness representations guide self-management. The model has primarily been used to understand how people self-manage physical health problems, we propose it may also be useful to understand self-management of mental health problems. The Common-Sense Model’s strengths-based perspective is a natural fit for the work of counseling psychologists. In particular, the model has important practical implicationsfor addressing how clients understand mental health problems over the course of treatment and self-manage these problems during and after treatment

Doctor recommendations are related to patient interest and use of behavioral treatment for chronic pain and addiction

The opioid crisis has highlighted the importance of improving patients’ access to behavioral treatments for chronic pain and addiction. What is not known is if patients are interested in receiving these treatments. In this cross-sectional study, over 1000 participants with chronic pain were surveyed using an anonymous online questionnaire on Amazon Mechanical Turk (Mturk) to investigate participants’ use of and interest in pharmacological and behavioral treatments for chronic pain and addiction. Participants also indicated whether their doctor had recommended these treatments. The majority of participants reported using medication for their pain (83.19%) and that their doctor recommended medication (85.05%), whereas fewer participants reported using (67.45%) and being recommended to (62.82%) behavioral treatments. We found 63.67% of participants screened positive for possible opioid misuse; those who screened positive were more interested in receiving behavioral treatments than those who did not screen positive. Participants who received treatment recommendations were more likely to be interested in receiving those treatments as compared to participants who did not. The results suggest that recommendations for behavioral treatments and interest in those treatments are related. Results also suggest that patients endorsing behaviors consistent with opioid misuse are interested in behavioral treatments

Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment

Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests that the pain management for these Veterans may need to be tailored to take CMI into consideration

“I Keep Hearing Reports on the News That it's a Real Problem at the Moment”: Public Health Nurses’ Understandings of Sexting Practices Among Young People

Over the past decade, the potential harms regarding young people's use of technology have attracted mounting political, media and research attention worldwide. One practice engaged in by many young people is that of “sexting” and the sharing of partially, or complete nude images (“selfies”). Such images are not always retained within private spaces and are prone to be shared, with significant psychosocial consequences for young people involved. A significant risk is the hidden nature of some online interactions, with potential for grooming and child sexual exploitation. As key professionals working with young people, public health nurses have potential to educate and explore the risks with them. Yet to date, to our knowledge there has been no research in relation to public health nurses’ understandings of the practices involved or their potential harms. A qualitative study was undertaken drawing theoretically on the common‐sense model (CSM) to frame the analysis. Eighteen semi‐structured interviews were conducted with public health nurses in a region of England in 2016. Data were analysed through thematic analysis, and mapped to the five domains of CSM. Public health nurses’ understandings of young people's sexting practices were shaped largely by media reports, rather than scientific, disciplinary knowledge. Sexting did not resonate with many public health nurses’ own experiences of being a young person and was therefore difficult to understand. All were able to express an opinion about the causes and consequences of sexting and we present these as a “perceived hierarchy of risk”. All public health nurses acknowledged the importance of their role in dealing with harm reduction associated with sexting among young people, but they need education and support to do this effectively and confidently. Findings can be transferred carefully to many contexts and countries because sexting is a practice among young people that transcends geographical boundaries

High Healthcare Utilization at the Onset of Medically Unexplained Symptoms

Objective: Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans to understand the relationship of increasing physical symptom burden to healthcare utilization. Methods: Data was examined from a prospective study of OEF/OIF veterans assessed before and one year after deployment (n=335). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA). Results: Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope = -0.26, F=4.07, p=0.04), specialist (slope = -.43, t=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope = -.41, t=5.71, p=0.02) and mental health (slope = -.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden. Conclusion: This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset

GHRH secretion from a pancreatic neuroendocrine tumor causing gigantism in a patient with MEN1.

Summary: A male patient with a germline mutation in MEN1 presented at the age of 18 with classical features of gigantism. Previously, he had undergone resection of an insulin-secreting pancreatic neuroendocrine tumour (pNET) at the age of 10 years and had subtotal parathyroidectomy due to primary hyperparathyroidism at the age of 15 years. He was found to have significantly elevated serum IGF-1, GH, GHRH and calcitonin levels. Pituitary MRI showed an overall bulky gland with a 3 mm hypoechoic area. Abdominal MRI showed a 27 mm mass in the head of the pancreas and a 6 mm lesion in the tail. Lanreotide-Autogel 120 mg/month reduced GHRH by 45% and IGF-1 by 20%. Following pancreaticoduodenectomy, four NETs were identified with positive GHRH and calcitonin staining and Ki-67 index of 2% in the largest lesion. The pancreas tail lesion was not removed. Post-operatively, GHRH and calcitonin levels were undetectable, IGF-1 levels normalised and GH suppressed normally on glucose challenge. Post-operative fasting glucose and HbA1c levels have remained normal at the last check-up. While adolescent-onset cases of GHRH-secreting pNETs have been described, to the best of our knowledge, this is the first reported case of ectopic GHRH in a paediatric setting leading to gigantism in a patient with MEN1. Our case highlights the importance of distinguishing between pituitary and ectopic causes of gigantism, especially in the setting of MEN1, where paediatric somatotroph adenomas causing gigantism are extremely rare. Learning points: It is important to diagnose gigantism and its underlying cause (pituitary vs ectopic) early in order to prevent further growth and avoid unnecessary pituitary surgery. The most common primary tumour sites in ectopic acromegaly include the lung (53%) and the pancreas (34%) (1): 76% of patients with a pNET secreting GHRH showed a MEN1 mutation (1). Plasma GHRH testing is readily available in international laboratories and can be a useful diagnostic tool in distinguishing between pituitary acromegaly mediated by GH and ectopic acromegaly mediated by GHRH. Positive GHRH immunostaining in the NET tissue confirms the diagnosis. Distinguishing between pituitary (somatotroph) hyperplasia secondary to ectopic GHRH and pituitary adenoma is difficult and requires specialist neuroradiology input and consideration, especially in the MEN1 setting. It is important to note that the vast majority of GHRH-secreting tumours (lung, pancreas, phaeochromocytoma) are expected to be visible on cross-sectional imaging (median diameter 55 mm) (1). Therefore, we suggest that a chest X-ray and an abdominal ultrasound checking the adrenal glands and the pancreas should be included in the routine work-up of newly diagnosed acromegaly patients