The patient experience of medically unexplained symptoms: an existentialist analysis

This article explores the patient experience of medically unexplained symptoms (MUS) from an existentialist standpoint. Drawing on the work of Jean-Paul Sartre and Simone de Beauvoir, I explore their concepts of existential situation, existential project, authenticity, and praxis. I then analyze the situation of MUS patients in the current cultural and institutional context, elucidating that a lack of explanation for their symptoms puts MUS patients in an existential bind. I illustrate the effects of the experience of MUS on patients’ existential projects. Last, I develop an ethical response in the existentialist tradition from the perspective of patients, providers, and society at large. I argue that there is a collective responsibility to foster conditions more conducive to authentic patient well-being and to improve the experience of patients with medically unexplained symptoms.

     

Psychosoma in crisis: an autoethnographic study of medically unexplained symptoms and their diverse contexts

In this study, we examine autoethnographic data from three critical incidents as experienced by the first author demonstrating the importance of context in understanding medically unexplained symptoms, their incidence and underlying patterns. We make the case for ethnographies as a crucial research strand in discerning the finer aspects of the patient or client experience; aspects that might be missed where people are directed along protocolised pathways of care. The article describes care as fragmented and depersonalising, leading to disembodied exchanges, as reflected in other autoethnographic studies, particularly those that highlight the complex relationship and controversies surrounding diagnostic uncertainty. We observe that psychological therapists, given the quality of the therapeutic relationship and sustained attention to the person’s experience, are well placed to assist in the necessary processes of re-contextualisation and re-embodiment.     

Childhood experience of illness as a risk factor for medically unexplained symptoms

Clinical experience suggests that a high proportion of patients with medically unexplained symptoms or somatoform disorders give histories of adverse childhood experiences. Previous work has reported that both personal and family experience of illness may be associated with later unexplained symptoms in the individual. Most of this research is subject to recall bias. This review explores data from the UK Medical Research Council National Survey of Health and Development, a population-based birth cohort study. The main finding of this work is that childhood experience of illness in parents is an independent risk factor for later unexplained symptoms. Personal experience of illness has a more complicated relationship. There is no evidence that severe physical disease in childhood is associated with later unexplained symptoms, but common childhood unexplained symptoms are predictors of symptoms in adulthood.     

At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.     

Employee commitment and motivation: a conceptual analysis and integrative model

Theorists and researchers interested in employee commitment and motivation have not made optimal use of each other's work. Commitment researchers seldom address the motivational processes through which commitment affects behavior, and motivation researchers have not recognized important distinctions in the forms, foci, and bases of commitment. To encourage greater cross-fertilization, the authors present an integrative framework in which commitment is presented as one of several energizing forces for motivated behavior. E. A. Locke's (1997) model of the work motivation process and J. P. Meyer and L. Herscovitch's (2001) model of workplace commitments serve as the foundation for the development of this new framework. To facilitate the merger, a new concept, goal regulation, is derived from self-determination theory (E. L. Deci & R. M. Ryan, 1985) and regulatory focus theory (E. I. Higgins, 1997). By including goal regulation, it is acknowledged that motivated behavior can be accompanied by different mindsets that have particularly important implications for the explanation and prediction of discretionary work behavior.     

Neurocognitive mechanisms of anxiety: an integrative account

Anxiety can be hugely disruptive to everyday life. Anxious individuals show increased attentional capture by potential signs of danger, and interpret expressions, comments and events in a negative manner. These cognitive biases have been widely explored in human anxiety research. By contrast, animal models have focused upon the mechanisms underlying acquisition and extinction of conditioned fear, guiding exposure-based therapies for anxiety disorders. Recent neuroimaging studies of conditioned fear, attention to threat and interpretation of emotionally ambiguous stimuli indicate common amygdala-prefrontal circuitry underlying these processes, and suggest that the balance of activity within this circuitry is altered in anxiety, creating a bias towards threat-related responses. This provides a focus for future translational research, and targeted pharmacological and cognitive interventions.     

Negative affect and 24-hour ambulatory physiological recordings as predictors of spontaneous improvement of medically unexplained symptoms

The predictive value for spontaneous improvement in individuals suffering from medically unexplained symptoms (MUS) was explored of (1) anxiety and depression obtained from questionnaires, (2) negative affective states obtained from experience-sampling, and (3) ambulatory-assessed real-life physiological recordings. Sixty-seven individuals with MUS and 61 healthy controls were included. Twenty-four hour ambulatory recordings of cardiac autonomic activity, respiration, end-tidal CO(2) and saliva cortisol were combined with experience-sampling of somatic complaints and mood. Complaints were assessed again after one year. Although a reduction in symptoms (25%) was found, this could not be predicted from initial anxiety and depression. Improvement was somewhat related to relatively low diary reports of fatigue, especially in the late-afternoon and evening (3% variance explained). From the physiological measures only relatively high PetCO(2) values in the morning predicted improvement (5% explained). It was concluded that spontaneous recovery from MUS is hard to predict from self-reported distress and ambulatory physiological recordings.     

Empathy, an integrative model

Empathy research has yielded various separate insights into empathy and its correlates. Yet a comprehensive theoretical account that situates these factors within a larger framework is lacking. In this paper a conception of empathy is proposed and defended, which makes it possible to provide an encompassing reconstruction of the processes that are characteristic of empathic encounters. This conception situates empathy within a context of communication. Doing so allows one to connect various treads in empathy research, but at the same time urges one to take new factors into account. It is argued that empathy is a response to a specific demand occurring in a specific context. The type of answer persons are able to provide depends on four types of factors. First, there are the psychological empathic components. We argue that empathy should be seen as a combination of (especially) parallel and reactive emotions, against a background of specific cognitive abilities. Second, it is argued that empathy is aided by a twofold control system, comprised of judgements and forms of self-control. Third, personality factors play a part in how a person responds to demands. Finally, but most importantly, it is pointed out that specific relational factors codetermine empathic reactions. In this paper we describe the theoretical background of our model and provide an elaborated account of the four factors that determine empathic acts in a given context. We illustrate the viability of our model by presenting observational data of children's empathic acts.     

Western esotericism: Towards an integrative model of interpretation

Despite the fact that during the last fifteen years we have witnessed the emergence of a research field of ‘Western esotericism’, scholars are still far from agreeing on definitions of ‘esotericism’. For an academic ‘field’, however, that wants to establish international networks and to bring together scholars from various research areas and disciplines, it is highly desirable to provide an interpretational framework in which these different studies find their place. The main argument of this article is that such common ground can be found only when esotericism is seen not as a selection of historical ‘currents’, however defined, but as a structural element of Western culture. After reviewing the most influential approaches to Western esotericism, this article identifies two dimensions of an esoteric discourse: claims of higher knowledge and ways of accessing this ‘truth’. To these dimensions can be added certain world views that are typically involved in there discourses. The interpretative model proposed here aims at critically addressing basic aspects of Western self-understanding including the rhetorics of rationality, science, enlightenment, progress and absolute truth. It postulates that conflicts of religious world views, identities and forms of knowledge lie at the heart of Western cultural history.     

Western esotericism: Towards an integrative model of interpretation

Despite the fact that during the last fifteen years we have witnessed the emergence of a research field of ‘Western esotericism’, scholars are still far from agreeing on definitions of ‘esotericism’. For an academic ‘field’, however, that wants to establish international networks and to bring together scholars from various research areas and disciplines, it is highly desirable to provide an interpretational framework in which these different studies find their place. The main argument of this article is that such common ground can be found only when esotericism is seen not as a selection of historical ‘currents’, however defined, but as a structural element of Western culture. After reviewing the most influential approaches to Western esotericism, this article identifies two dimensions of an esoteric discourse: claims of higher knowledge and ways of accessing this ‘truth’. To these dimensions can be added certain world views that are typically involved in there discourses. The interpretative model proposed here aims at critically addressing basic aspects of Western self-understanding including the rhetorics of rationality, science, enlightenment, progress and absolute truth. It postulates that conflicts of religious world views, identities and forms of knowledge lie at the heart of Western cultural history.     

Structures,dynamics and mechanisms in neuroscience: an integrative account

Proponents of mechanistic explanations have recently proclaimed that all explanations in the neurosciences appeal to mechanisms. The purpose of the paper is to critically assess this statement and to develop an integrative account that connects a large range of both mechanistic and dynamical explanations. I develop and defend four theses about the relationship between dynamical and mechanistic explanations: that dynamical explanations are structurally grounded, that they are multiply realizable, possess realizing mechanisms and provide a powerful top-down heuristic. Four examples shall support my points: the harmonic oscillator, the Haken–Kelso–Bunz model of bimanual coordination, the Watt governor and the Gierer–Meinhardt model of biological pattern formation. I also develop the picture of “horizontal” and “vertical” directions of explanations to illustrate the different perspectives of the dynamical and mechanistic approach as well as their potential integration by means of intersection points.     

Psychological effects of risk glorification in the media: Towards an integrative view

Media contents that glorify risk-taking (e.g., video games that simulate illegal street racing, TV depictions of dangerous extreme sports or stunts) are becoming increasingly popular. Theory and research suggest that risk glorification is associated with risk-taking among the audience. Until recently the evidence was limited in three ways: First, most studies, being correlational, did not permit clear causal inferences. Second, we did not know the strength of the effect of different types of media and different types of risk-taking outcomes. Third, early research did little to isolate the underlying psychological processes that mediate the pernicious effects of risk glorifying media formats. In order to address these open questions we review the results of an experimental programme of research and the findings of a comprehensive meta-analysis. The main findings are that (a) the risky media contents do indeed have causal force; (b) according to our meta-analysis active participation in risk glorifying media interfaces has a larger effect than passive consumption; (c) psychological processes include the priming of risk-related constructs, effects of risk-positive situational heuristic cues, perceived social norms, personal risk habituation, and changes in the recipient's self-concept. To integrate these findings we propose a theoretical framework derived from broad-range socio-cognitive models. We conclude with a discussion of possible directions for future research.     

Covariational influences on goal-based explanation: an integrative model

Covariational and goal-based approaches to social attribution have been treated as competitive or incommensurable. This article integrates key aspects of each approach. Four studies examined preferences for motivating factors (or goals) and enabling factors (or preconditions) as explanations of intentional actions. The studies manipulated (Studies 1-3) and measured (Study 4) the perceived covariation of these goal-based causes with target actions. Causes that covaried with actions were preferred explanations, in contrast with the goal-based view that motivating factors are generally preferred to enabling factors. Combining goal-based beliefs and covariational reasoning resolves problems faced by each individual approach and generates a novel explanatory typology that combines strengths of goal-based and covariational typologies.     

The development of a brief group intervention (Dynamic Interpersonal Therapy) for patients with medically unexplained somatic symptoms: a pilot study

The primary aim of this equivalence study was to compare the outcome of a brief group therapeutic intervention, based on the principles of dynamic interpersonal therapy (DIT) with an intervention based on cognitive behavioural therapy (CBT) in patients suffering from medically unexplained somatic symptoms (MUSS). Participants were 89 patients (aged 18 to 62) who were offered 20 sessions of either DIT or CBT, as central part of a treatment package, consisting of art therapy, psychomotor therapy, social therapy and physical therapy. Measurements were conducted at baseline, 10 weeks and 20 weeks, using self-rating scales measuring the level of anxiety and depression, the severity of medically unexplained symptoms and quality of life. Results showed that CBT and DIT were comparable. The conclusion was that it is recommended to design a larger scale randomised controlled trial to further elaborate the short-term and long-term effects of this novel psychodynamic group therapy for MUSS patients.     

Systemic-motivational therapy for substance abuse disorders: an integrative model

Although recent reviews of the literature on families and substance misuse offer compelling evidence that inclusion of families significantly improves treatment engagement, retention and outcome, family therapy remains peripheral in most substance abuse treatment programmes. Furthermore, many of the treatment approaches that have been included under the term 'family therapy' continue to focus on the substance abuser as the sole target of treatment. Still conspicuously absent are treatment models based on family systems approaches, with outcomes targeted at non-abusing family members as well. This article presents an overview of one such family-focused substance abuse treatment model – systemic-motivational therapy – that combines a family systems approach with techniques derived from motivational interviewing, but this time is applied to work with the family as a unit. The background for the development of the model will be described, as well as the assessment/consultation, family-level action plan, and aftercare/relapse prevention phases of the treatment approach.