Danielle Groleau

Explaining Medically Unexplained Symptoms

Patients with medically unexplained symptoms comprise from 15% to 30% of all primary care consultations. Physicians often assume that psychological factors account for these symptoms, but current theories of psychogenic causation, somatization, and somatic amplification cannot fully account for common unexplained symptoms. Psychophysiological and sociophysiological models provide plausible medical explanations for most common somatic symptoms. Psychological explanations are often not communicated effectively, do not address patient concerns, and may lead patients to reject treatment or referral because of potential stigma. Across cultures, many systems of medicine provide sociosomatic explanations linking problems in family and community with bodily distress. Most patients, therefore, have culturally based explanations available for their symptoms. When the bodily nature and cultural meaning of their suffering is validated, most patients will acknowledge that stress, social conditions, and emotions have an effect on their physical condition. This provides an entree to applying the symptom-focused strategies of behavioural medicine to address the psychosocial factors that contribute to chronicity and disability.

The McGill Illness Narrative Interview (MINI): An Interview Schedule to Elicit Meanings and Modes of Reasoning Related to Illness Experience

This article summarizes the rationale, development and application of the McGill Illness Narrative Interview (MINI), a theoretically driven, semistructured, qualitative interview protocol designed to elicit illness narratives in health research. The MINI is sequentially structured with three main sections that obtain: (1) A basic temporal narrative of symptom and illness experience, organized in terms of the contiguity of events; (2) salient prototypes related to current health problems, based on previous experience of the interviewee, family members or friends, and mass media or other popular representations; and (3) any explanatory models, including labels, causal attributions, expectations for treatment, course and outcome. Supplementary sections of the MINI explore help seeking and pathways to care, treatment experience, adherence and impact of the illness on identity, self-perception and relationships with others. Narratives produced by the MINI can be used with a wide variety of interpretive strategies drawn from medical anthropology, sociology and discursive psychology.

Shared decision-making in palliative care: A systematic mixed studies review using narrative synthesis

The aim of this study is to synthesize knowledge about the process of shared decision-making (SDM) in palliative care. Medline, EMBASE, CINAHL, PsychInfo, Web of Science were searched with core concepts: shared decisions, patient participation in decision-making, and palliative care. Titles and abstracts were screened according to inclusion criteria (original research, adult patients, Western contexts, decision-making, palliative treatment or setting), yielding 37 articles for analysis. A narrative synthesis was created using the methods of thematic analysis, conceptual mapping, and critical reflection on the synthesis process. Results demonstrate that while a majority of patients want to participate in treatment decisions to some extent, most do not achieve their preferred levels of involvement because decisions are delayed and alternative treatment options are seldom discussed. The literature regarding the process of SDM itself remains scarce in palliative care. Further research is needed in order to better understand the longitudinal, interactive, and interdisciplinary process of decision-making in palliative care.

AFFECTIVE DISORDERS IN CULTURAL CONTEXT

This article reviews epidemiologic and ethnographic evidence for the cultural shaping of the causes, symptomatology, and course of affective disorders. Cross-cultural research demonstrates much overlap of depression with anxiety, somatoform, and dissociative disorders, raising questions about the universality of the prototypical representation of depression in North American psychiatry. Culture-specific symptoms may lead to under-recognition or misidentification of syndromes of mania and depression in many ethnocultural groups. Cultural idioms of distress may employ symptoms related to affective disorders to express sentiments and perceptions that do not in themselves indicate psychopathology. Socially mediated cognition about the self and specific modes of interpersonal interaction influence the course of depression. This article discusses some implications of these findings for the recognition and treatment of affective disorders among culturally diverse populations in primary care and mental health care settings.

Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of Psychosis Among Ethnoculturally Diverse Patients

OBJECTIVE The aim of the study was to assess the impact of systematic use of the DSM-IV-TR cultural formulation on diagnoses of psychotic disorders among patients of ethnic minority and immigrant backgrounds referred to a cultural consultation service (CCS) in Canada. METHODS The study entailed a review of medical records and case conference transcripts of 323 patients seen in a ten-year period at the CCS to determine factors associated with change in the diagnosis of psychotic disorders by the CCS. Logistic regression analysis was used to identify variables associated with changes in diagnosis. RESULTS A total of 34 (49%) of the 70 cases with an intake (referral) diagnosis of a psychotic disorder were rediagnosed as nonpsychotic disorders, whereas only 12 (5%) of the 253 cases with an intake diagnosis of a nonpsychotic disorder were rediagnosed as a psychotic disorder (p<.001). Major depression, posttraumatic stress disorder (PTSD), adjustment disorder, and bipolar affective disorder were the common disorders diagnosed with use of the cultural formulation. Rediagnosis of a psychotic disorder as a nonpsychotic disorder was significantly associated with being a recent arrival in Canada (odds ratio [OR]=6.05, 95% confidence interval [CI]=1.56-23.46, p=.009), being nonblack (OR=3.72, CI=1.03-13.41, p=.045), and being referred to the CCS by nonmedical routes (such as social work or occupational therapy) (OR=3.23, CI=1.03-10.13, p=.044). CONCLUSIONS Misdiagnosis of psychotic disorders occurred with patients of all ethnocultural backgrounds. PTSD and adjustment disorder were misidentified as psychosis among immigrants and refugees from South Asia. Studies are needed that compare clinical outcomes of use of cultural consultation with outcomes from use of other cultural competence models.

Barriers, Facilitators, and Recommendations Related to Implementing the Baby-Friendly Initiative (BFI): An Integrative Review

Despite growing evidence for the positive impact of the Baby-Friendly Initiative (BFI) on breastfeeding outcomes, few studies have investigated the barriers and facilitators to the implementation of Baby-Friendly practices that can be used to improve uptake of the BFI at the local or country levels. This integrative review aimed to identify and synthesize information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature. Thirteen databases were searched using the keywords Baby Friendly, Baby-Friendly Hospital Initiative, BFI, BFHI, Ten Steps, implementation, adoption, barriers, facilitators, and their combinations. A total of 45 English-language articles from 16 different countries met the inclusion criteria for the review. Data analysis was guided by Cooper’s five stages of integrative research review. Using a multiple intervention program framework, findings were categorized into sociopolitical, organizational-level, and individual-level barriers and facilitators to implementing the BFI, as well as intra-, inter-, and extraorganizational recommendations for strengthening BFI implementation. A wide variety of obstacles and potential solutions to BFI implementation were identified. Findings suggest some priority issues to address when pursuing Baby-Friendly designation, including the endorsements of both local administrators and governmental policy makers, effective leadership of the practice change process, health care worker training, the marketing influence of formula companies, and integrating hospital and community health services. Framing the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services.

Enhancing Generalizability: Moving From an Intimate to a Political Voice:

Weak external validity of qualitative data has been a subject of debate outside and within the field of qualitative health research. Though some narratives have the power to reveal universal existential issues and inform theoretical development, each story remains unique and cannot be generalized. If the goal of qualitative researchers is to have narrative knowledge effect social change, we are faced with a pervasive problem. Our main objective with this article is methodological; that is, to argue and illustrate that a sequential—consensual qualitative design can yield data with adequate external validity to influence clinicians and public health programming. We seek to contribute to the debate on the generalizability of qualitative research in the health field and provide a methodological template for this type of qualitative design so researchers can apply it to future projects to transfer and translate popular knowledge in a way that can influence social change.

Training Researchers in Cultural Psychiatry: The McGill-CIHR Strategic Training Program

ObjectivesThe authors aim to summarize the pedagogical approaches and curriculum used in the training of researchers in cultural psychiatry at the Division of Social and Transcultural Psychiatry at McGill University.MethodWe reviewed available published and unpublished reports on the history and development of the McGill cultural psychiatry programs to identify the main orientations (conceptual and methodological), teaching methods, curriculum and course content. Student evaluations of teaching were reviewed. Follow-up data on research and other academic activities and employment of trainees who graduated from the program was obtained by e-mail questionnaire.ResultsThe McGill program includes a Master of Science program, an intensive summer school, annual Advanced Study Institutes, and the McGill-CIHR Strategic Training Program in Culture and Mental Health Services Research. The interdisciplinary training setting emphasizes the cultural history and embedding of psychiatric knowledge and practice; the social construction of ethnicity, race, and cultural identity; the impact of globalization, migration, and ideologies of citizenship on individual identity and the configuration of cultural communities; and the integration of quantitative and qualitative ethnographic methods in basic and evaluative research.ConclusionThis critical transdisciplinary approach provides researchers with conceptual tools to address the impact of the changing meanings of culture and ethnicity difference in the contemporary world on mental health services.

Public Pressure, Private Protest: Illness Narratives of West Indian Immigrants in Montreal with Medically Unexplained Symptoms

Some evidence suggests that West Indian immigrants in Canada are a marginalized and over-burdened group. However, little attention has been given to examining health status and beliefs. We partly redress this gap by investigating health beliefs of West Indian immigrants in Montreal with somatic, emotional, or medically unexplained symptoms. The overall aim was to elicit and explore illness narratives, explanatory models, symptom-attribution and help-seeking in the community. A sample of 15 West Indian immigrants took part in semi-structured interviews. We found that participants overwhelmingly ascribed their symptoms to post-migratory experience. They particularly highlighted the importance of two related factors: chronic overwork since migration and irregular patterns of daily living. Many worked long hours, including overtime and moonlighting. Participants related their irregular patterns of daily living to disturbances of bodily functions (e.g., sleeping, eating) as well as to social functions (e.g., family life). These themes reflected elements of ethno-physiological beliefs common in the West Indies, as well as North American illness models. Attributing medically unexplained symptoms to overwork and irregularity in personal and social realms may be a socially acceptable way of critiquing perceived injustices in participants’ work, social and interpersonal situations. This is especially so because the dominant discourse regarding race and ethnicity in Canada tends to emphasize positive aspects of multiculturalism—only reluctantly acknowledging conflict and inequality. Narratives could be interpreted as an oblique criticism of Canadian societys apparent indifference to participants’ ongoing marginalization.

Patients diagnosed with nonepileptic seizures: Their perspectives and experiences

The objective of this qualitative study was to examine how patients with nonepileptic seizures (NES) make sense of their illness experience in light of the many obstacles they may face when seeking treatment. We conducted semistructured interviews with five patients with NES to explore their illness perspectives and different modes of reasoning in regard to their illness and treatment experiences. The data were examined using thematic content analysis. The participants who implicitly incorporated epilepsy as an illness prototype demonstrated less effective treatment expectations and imposed greater life constraints on themselves than the participant who used anxiety attacks. The participants who defined an explanatory model with a psychosocial basis for illness onset were receptive and demanding of psychotherapeutic intervention. Emergent themes included accounts of adverse and positively perceived life events coinciding with illness onset, head injury, presence of caregivers during events, comorbid illness, and previously witnessing epilepsy in others.