Sarah Peters

Patients with medically unexplained symptoms : Sources of patients' authority and implications for demands on medical care

Lay and medical beliefs are not separate systems. The beliefs of somatizing patients, in particular, incorporate medical understanding and it has been argued that this increases the power that such patients exert in seeking treatment from doctors. To understand the nature and use of this power requires investigation of (i) how patients use medical ideas and language to explain their symptoms and (ii) how this process influences patients expectations and evaluations of their doctors. We interviewed 68 patients, in whom no physical cause had been found for persistent physical symptoms. Their accounts of symptoms and of their experience of doctors were subjected to qualitative thematic analysis. As expected, patients used medical terms to explain their symptoms. However, these depicted explanatory themes which have long been familiar in traditional lay models: disease as a malign entity and imbalance between bodily forces. Patients sense of authority over doctors derived, not from facility with medical language and ideas but from contrasting their own sensory, and therefore infallible, experience of symptoms with doctors indirect and fallible knowledge. By providing explanations that questioned the reality of symptoms, doctors were perceived as incompetent and inexpert. Patients used their authority, not to seek treatment, but to secure naming of, and collaboration against, the disorder. Although these patients saw the doctors role as limited and inexpert by comparison with their own, our analysis suggests ways in which doctors might more effectively engage with persistent somatizing patients.

Expressed emotion, attributions and depression in mothers of children with problem behaviour

BACKGROUNDnThis was an initial study seeking to examine the relationship between Expressed Emotion (EE), spontaneous causal attributions and depression in mothers of children referred for problem behaviour.nnnMETHODnSixty-one mothers were interviewed using the Camberwell Family Interview (CFI). The CFI was coded for maternal EE and spontaneous causal attributions regarding the childs behaviour. Self-report measures of child problem behaviour and maternal depressive symptoms were also completed.nnnRESULTSnConsistent with previous research, high EE mothers, compared to low EE mothers, were more likely to make attributions thatjudged the cause of problem behaviour to be personal to and controllable by the child and also made more child-blaming attributions than low EE mothers. Mothers scores on the Beck Depression Inventory were found to be associated with child-blaming attributions and higher levels of EE. Regression analyses did not support the hypothesised role of attributions as a mediator between depression and EE but did identify EE as a potential mediator in the relationship between maternal depressed mood and ratings of child problem behaviour.nnnCONCLUSIONSnThese results indicate the relevance of both EE and attributions in mothers of children with problem behaviour and suggest that maternal depressed mood is an important factor which is related to both of these.

Why do general practitioners decline training to improve management of medically unexplained symptoms

BackgroundGeneral practitioners’ (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients’ problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it.ObjectiveTo identify how GPs’ attitudes to patients with MUS might inhibit their participation with training to improve management.DesignQualitative study.ParticipantsGPs (Nu2009=u200933) who had declined or accepted training in reattribution techniques in the context of a research trial.ApproachGPs were interviewed and their accounts analysed qualitatively.ResultsAlthough attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills.ConclusionsGPs’ attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.

A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms.

Objective: To re-examine the widespread assumption that medically unexplained physical symptoms represent discrete syndromes resulting from somatization of mental illness. Method: Primary care patients (N = 223) with medically unexplained symptoms of at least one years duration were recruited to a study of exercise therapy. Data gathered from patients, from their general practitioners, and from medical records were used to examine relationships between self-defined disability, symptoms, mental state, and use of health care. Results: Levels of disability and health care use were both raised, but were only weakly correlated. While most patients were depressed and/or anxious, a minority (14 percent) were neither. Although mental state correlated with disability, health care use was unrelated to either. Among a wide range of recorded symptoms, few correlations were found to support the existence of discrete syndromes. Analysis of agreement between patients and their doctors in assigning symptoms to broadly defined “syndromes” appears to reflect collaboration that is largely expedient. Conclusions: In this sample of primary care patients with persistent unexplained physical symptoms, we found little evidence of discrete somatic syndromes. The level of health care use is no indication of mental state or level of disability, and the findings are equally consistent with depression or anxiety being secondary to disability and its consequences as with them being primary. The observed collaboration between patients and their doctors carries the risk of shaping, reinforcing, and legitimizing dubious syndromes.

Fatigue Intervention by Nurses Evaluation – The FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610]

BackgroundChronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP).Methods and designThis study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions mechanisms of change, and also GPs drivers and barriers towards referral.

Relevant behavioural and social science for medical undergraduates: a comparison of specialist and non‐specialist educators

Aimu2002 To compare what medical educators who are specialists in the behavioural and social sciences and their non‐specialist counterparts consider to be core concepts that medical graduates should understand.

A dissociation between the ability to print and write cursively in lower-case letters

This paper reports the case of a patient with a peripheral spelling impairment who is much more severely impaired at writing in lower-case letters than in upper-case letters. This pattern can be observed when writing both words and single letters of the alphabet. Despite this, his problems in writing lower-case letters are no longer present when he is writing cursively. This case therefore indicates that the ability to print letters in lower-case can be selectively impaired in the absence of similar problems in printing upper-case letters or in writing lower-case letters cursively. In terms of the model of writing put forward by Ellis (1982, 1988), this suggests that allographic level representations for print handwriting styles can be functionally dissociated from allographic representations for cursive styles.

Allograph errors and impaired access to graphic motor codes in a case of unilateral agraphia of the dominant left hand

This paper describes the case of a unilateral agraphic patient (GG) who makes letter substitutions only when writing letters and words with his dominant left hand. Accuracy is significantly greater when he is writing with his right hand and when he is asked to spell words orally. GG also makes case errors when writing letters, and will sometimes write words in mixed case. However, these allograph errors occur regardless of which hand he is using to write. In terms of cognitive models of peripheral dysgraphia (e.g., Ellis, 1988), it appears that he has an allograph level impairment that affects writing with both hands, and a separate problem in accessing graphic motor patterns that disrupts writing with the left hand only. In previous studies of left-handed patients with unilateral agraphia (Zesiger & Mayer, 1992; Zesiger, Pegna, & Rilliet, 1994), it has been suggested that allographic knowledge used for writing with both hands is stored exclusively in the left hemisphere, but that graphic motor patterns are represented separately in each hemisphere. The pattern of performance demonstrated by GG strongly supports such a conclusion.