Enhancing quality of life in medical populations: a vision for body image assessment and rehabilitation as standards of care

This article presents a vision and framework for establishing body image assessment and rehabilitation as a standard of care for patients with medical disorders. Making this vision a reality depends upon: (1) a thorough understanding of the body image construct; (2) application of many new forms of body image assessment; (3) refined understanding of body image disorder and dysfunction in the context of medical conditions; and (4) a clear plan to implement and evaluate prevention, rehabilitation, and treatment programs. Applying the many important developments that have occurred in body image theory, assessment, and intervention over the past decade holds promise for enhancing the quality of life of many individuals with medical conditions.     

Perspectives on Genetic Testing and Return of Results from the First Cohort of Presymptomatically Tested Individuals At Risk of Huntington Disease

This qualitative study gathered opinions about genetic testing from people who received presymptomatic testing for Huntington’s disease (HD) 20–30 years ago and have lived with the implications of that testing for decades. During the last section of a semi-structured interview, participants were asked open-ended questions about their opinions on the importance of autonomy in the decision to be tested for HD, whether a formal HD testing protocol is necessary, whether physician ordering for HD is acceptable without a formal protocol, whether online direct-to-consumer (DTC) genetic testing for HD is acceptable, and whether incidental/secondary findings should be returned in the context of whole exome/genome sequencing. Most—but not all—participants were in favor of an individual’s right to decide whether and when to pursue HD testing, use of a formal HD testing protocol, and returning medically actionable secondary findings. However, the majority of participants were opposed not only to physician ordering and DTC HD testing in the absence of a formal protocol but also to returning a secondary finding of an expanded HD allele. This study presents the opinions of a unique and extremely well-informed cohort on issues that need to be taken into careful consideration by genetic counselors and other medical professionals who are developing genetic testing protocols, making decisions about the availability of genetic tests, and making decisions about whether and how to return incidental findings.     

Frequent Assessment of Negative Symptoms Does Not Induce Depressed Mood

Use of real-time data collection is rapidly expanding in the medical sciences and questions have been raised as to whether frequent ratings of disease symptoms could evoke depressed mood. This study investigated the effect of an intensive momentary assessment protocol on depressed mood. Community rheumatology patients (N = 105) were recruited to participate in a 30-day momentary assessment protocol of pain and fatigue. Patients were randomly signaled and completed approximately 6 ratings per day and at bedtime. Beck Depression Inventory-II scores were obtained prior to and at the completion of the protocol. Thirty-six percent of patients were classified initially as mild to severely depressed, and 31% percent at the end of the protocol. Depression scores were significantly lower following the protocol (p < .001). Whereas 10% of patients shifted into a more depressed category at the end of the protocol, 20% shifted into a less depressed category. These findings suggest frequent assessment of pain and fatigue may not induce depressed mood, and may in some instances be associated with a small reduction in depressed mood.     

Adapting Cognitive-Behavioral Therapy for Depressed Adolescents Exposed to Interpersonal Trauma: A Case Study With Two Teens

A substantial body of evidence indicates that interpersonal trauma increases risk for adolescent and adult depression. Findings from 4 clinical trials for adolescent depression show poorer response to standard cognitive-behavioral therapy (CBT) among depressed adolescents with a trauma history than youth without such a history. This paper reports on the development of a modified CBT (mCBT) protocol that has been adapted for treating depressed adolescents who have been exposed to traumatic interpersonal events (physical/sexual abuse or witnessing domestic violence). First, we provide an empirical rationale for targeting executive function deficits and trauma-related cognitions in the mCBT protocol. Second, we present promising results from 2 community clinic cases.     

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

The onset of appearance-related concerns associated with body dysmorphic disorder (BDD) typically occurs in adolescence, and these concerns are often severe enough to interfere with normal development and psychosocial functioning. Cognitive behavioral therapy (CBT) is an effective treatment for adults with BDD. However, no treatment studies focusing on adolescents with BDD have been conducted. The need for an effective treatment in this population led to the development of a brief CBT protocol with family involvement. The treatment focuses on enhancing an adolescent's quality of life through the reduction of maladaptive thoughts and behaviors, and incorporates skills training and parent training. Similar treatment packages have already been shown to be efficacious for children and adolescents with similar disorders, such as obsessive-compulsive disorder and social phobia. The following case illustrates the application of this brief CBT protocol for BDD in an adolescent, and highlights clinical considerations needed when adapting CBT for a pediatric population. Treatment was associated with clinically significant improvement in symptoms of BDD, self-esteem, depression, and quality of life. This report extends extant literature by suggesting that CBT may be a helpful treatment for adolescents with BDD.     

‘No entry’, an invitation to intrude,or both? Reflections on a group of anorexic patients

This paper describes the twice‐weekly psychoanalytic psychotherapy of a young woman who had undergone major bowel surgery in her early 20s, with no clear medical indication for the surgery. Whilst the concept of ‘No Entry’ described by Williams ( 1997a , b ) aptly describes many features of more ‘typical’ anorexic patients, this paper describes a particular group of anorexic patients, referred by their physicians for multiple medical procedures; and proposes there is a group of anorexic patients, repeatedly referred for medical investigations, into whom particular types of entries occur. These are entries into the body ‘legitimized’ as medical, with a trajectory towards multiple procedures, examinations and surgical operations. Other entries (outside the medical setting) may occur in a state of altered consciousness, under the influence of alcohol or drugs, such that any wish for intrusion is disowned and denied. In both sets of events, intrusion is both invited, and consciously denied. The case example illuminates some of these features, and aspects of the countertransference are also described. Attention is drawn to relevant research focusing on surgical intrusion. Finally, there is an exploration as to how such patients may invite intrusions into the body through surgery and medical procedures.     

Prototype-distortion category learning: a two-phase learning process across a distributed network

This paper reviews a body of work conducted in our laboratory that applies functional magnetic resonance imaging (fMRI) to better understand the biological response and change that occurs during prototype-distortion learning. We review results from two experiments (Little, Klein, Shobat, McClure, & Thulborn, 2004; Little & Thulborn, 2005) that provide support for increasing neuronal efficiency by way of a two-stage model that includes an initial period of recruitment of tissue across a distributed network that is followed by a period of increasing specialization with decreasing volume across the same network. Across the two studies, participants learned to classify patterns of random-dot distortions (Posner & Keele, 1968) into categories. At four points across this learning process subjects underwent examination by fMRI using a category-matching task. A large-scale network, altered across the protocol, was identified to include the frontal eye fields, both inferior and superior parietal lobules, and visual cortex. As behavioral performance increased, the volume of activation within these regions first increased and later in the protocol decreased. Based on our review of this work we propose that: (i) category learning is reflected as specialization of the same network initially implicated to complete the novel task, and (ii) this network encompasses regions not previously reported to be affected by prototype-distortion learning.     

The value of emotionally expressive visual art in medical education

This paper approaches the topic of visual art in medical education from a philosophical perspective, drawing on arguments from epistemology, philosophy of science, aesthetics, and contemporary ethical theory. Several medical ethicists have noted that the traditional clinical paradigm may increase the epistemic and emotional distance between patient and physician in part by focusing on the physical body and medical technology. Some of these same writers recommend a new approach to patients based on empathy and increased attention to suffering. After reviewing these arguments, supporting examples, and recommendations, I explain how visual art that expresses or symbolizes the emotional response to illness could be used to introduce an additional paradigm into medical education. This would be a paradigm based on empathetic attention to patients' emotional experiences in illness. My own argument is that this additional way of perceiving and relating to patients may reduce the distance between patient and physician and may allow physicians to better meet the ideal of treating the patient as a person.     

Does the burden of the experience sampling method undermine data quality in state body image research?

Despite growing popularity of experience sampling methodology (ESM) for evaluations of state-based components of body image, there have been concerns that the frequent repeated measurement might encourage problematic responding resulting in low data quantity and/or quality. Using a sample of 105 women (mean age = 24.84), this study used multilevel modelling to investigate whether (a) there were changes in compliance or response variability across a 7-day period, and (b) whether such changes are explained by participant characteristics. Present findings suggest that demands of ESM protocol undermine quantity more so than quality of obtained data. Decline in procedural compliance across the testing period correlated with BMI and body shame, whereas reduced variability in state-based assessments did not adversely impact the strength of association between state body satisfaction ratings and other variables in the dataset. The authors make several recommendations for ensuring the quality of ESM-based data in future studies.     

Altered Sexuality and Body Image after Gynecological Cancer Treatment: How Can Psychologists Help?

Once medical treatment for gynecological cancer is completed, what happens to patients' sexuality and body image? Due to the delicate nature of the cancer site, treating this cancer typically affects sexual functioning and body image adversely, making it critical to identify the concerns of these patients and do so in a manner less restrictive than paper-and-pencil assessment. To gain a deeper understanding of the phenomenological experiences in question, we interviewed nine gynecological cancer patients and seven cancer-free women. After implementing a relaxation protocol, we asked each woman to describe her feelings and thoughts on her sexuality and body image in one-on-one interviews. A variety of themes emerged on patients' attitudes and perspectives concerning sexuality and body image following diagnosis and treatment of the cancer. The themes that were considerably different from those of the cancer-free women included decreased sexual functioning and body image, abrupt shifts in self-identity due to loss of physical integrity, and distancing in intimate relationships. Several implications of these findings for clinical practice are discussed, as well as the need to train medical professionals to properly assess these patients' alterations in sexuality.     

On Opening Panoora's Box

Summary

The problem of partner violence has assumed a level of importance in the field of medicine only within the past 5 to 10 years. Impetus for this increased interest lies with strong leadership from two previous surgeons general. Another source of impetus is a growing research body which clearly shows that violence, especially partner violence, (a) is not rare in medical settings, and (b) results in considerable morbidity and mortality. This article briefly reviews research on incidence and prevalence of violence victimization among medical system utilizers. Literature illustrating a dearth of physician identification and response to victims of violence is also considered. Finally, given the high rates of violence victims in medical practice and the relative lack of appropriate physician response, it is argued that a need exists for physician training in identification and intervention with violence victims.     

After Novelty: The Mundane Practices of Ensuring a Safe and Stable Supply of Bone

New medical technologies to a great extent use material from human bodies as therapeutic tools. Social science studies of such ‘tools’ have tended to focus on technologies associated with novelty and drama. This paper, in contrast, concerns an old, well-entrenched and ostensibly undramatic technology, bone transfers, that has only recently gained public attention. The history of bone transplants is intertwined with a desire for a safe and stable supply of bone. This desire has a number of rarely debated social implications of relevance to transplant medicine in general: the gradual industrialization of procurement; the institutional production of the view of the body as a dividable resource; the emergence of a notion of scarcity; of body parts as waste; of death as a productive moment in which body parts acquire potential exchange value; and of tensions between an ethics of respect for donors and an ethics of efficient procurement. Historical analysis combined with a contemporary phenomenological approach suggests that the ‘newness’ typically associated with usage of human biological material is not related to transplant technologies as a medical discipline as such, but rather to changes in its social organization and features of the everyday experience of living with the transplant technologies.     

L’affaire Lambert et la Convention internationale relative aux droits des personnes handicapées (CIDPH)

While the Conseil d’État once again confirmed the legality of the medical decision to stop treatment of Vincent Lambert, the Cour de Cassation held that the French State is not required to suspend the execution of the said decision pending the opinion of the Committee on the Rights of Persons with Disabilities, a United Nations’ body. Nevertheless, the High jurisdiction does not directly pronounce itself on the question of the binding force of the provisions of the Convention on the Rights of Persons with Disabilities and its additional protocol, nor on the scope of these texts.     

Statutory definitions of death and the management of terminally ill patients who may become organ donors after death

The law stipulates that death is irreversible. Patients treated in accord with the Pittsburgh protocol have death pronounced when their condition might well be reversed by intervention that is intentionally withheld. Nevertheless, the protocol is in accord with the medical "Guidelines for the Determination of Death." However, the Guidelines fail to capture the intent of the law, which turns out to be a good thing, for the law embodies a faulty definition of death. The inclusion of "irreversible" in the legal definition makes that definition excessively demanding and out of step with the ordinary concept of death. On this basis the protocol is absolved of the moral but not the legal charge that it involves vivisection.     

Reclaiming Embodiment within Critical Psychology: A Material‐Discursive Analysis of the Menopausal Body

Social and Critical Psychology have been accused of ‘disembodying’ the discipline through the negation of embodied experience. In contrast, Bio‐Medicine and Biological Psychology focus on the body, within a realist framework. A material‐discursive approach, and a critical‐realist epistemology, is proposed as a way forward to examine embodiment in a socio‐cultural context, wherein the materiality of the body is recognised, but always mediated by culture, language, and subjectivity. As a case example, women's experience of embodied change at menopause is examined. The bio‐medical positioning of the menopausal body as the site of disease, distress, and debilitation, necessitating medical management, is contrasted with women's reports of minimal distress, and effective negotiation of midlife changes. Cultural context, relational factors and the positioning of embodied changes as symptoms, or as natural, are key factors determining women's coping. This material‐discursive approach thus allows us to ‘re‐embody’ psychology and move beyond the mind–body divide.     

Body image and cosmetic medical treatments

Cosmetic medical treatments have become increasingly popular over the past decade. The explosion in popularity can be attributed to several factors—the evolution of safer, minimally invasive procedures, increased mass media attention, and the greater willingness of individuals to undergo cosmetic procedures as a means to enhance physical appearance. Medical and mental health professionals have long been interested in understanding both the motivations for seeking a change in physical appearance as well as the psychological outcomes of these treatments. Body image has been thought to play a key role in the decision to seek cosmetic procedures, however, only recently have studies investigated the pre- and postoperative body image concerns of patients. While body image dissatisfaction may motivate the pursuit of cosmetic medical treatments, psychiatric disorders characterized by body image disturbances, such as body dysmorphic disorder and eating disorders, may be relatively common among these patients. Subsequent research on persons who alter their physical appearance through cosmetic medical treatments are likely provide important information on the nature of body image.     

Assessing body image in patients with systemic sclerosis (scleroderma): validation of the adapted Satisfaction with Appearance Scale

People with scleroderma often experience disfiguring appearance-related changes in socially visible and interpersonally salient areas. Although disfigurement can lead to body image dissatisfaction, this phenomenon has not been well investigated due to the lack of a disfigurement-specific measure. The Satisfaction With Appearance (SWAP) scale, previously developed in burn survivors, was adapted and administered to 254 participants with scleroderma to evaluate its psychometric integrity and its validity for use in a different medical population that experiences changes in appearance. Principal component analysis revealed two factors – Subjective Dissatisfaction and Perceived Social Impact – rather than the four found in burn victims. Excellent estimates of internal consistency and temporal stability and strong evidence for the reliability of the two-factor solution were found. The resulting factor structure in a scleroderma population suggests that differing medical conditions may create alternate constellations of BID, reflects the need for body image researchers to assess psychometrics across medical populations and may have clinical implications for BID interventions.