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.

     

Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model

Theories of medically unexplained illness based on the concepts of dissociation, conversion, and somatization are summarized. Evidence cited in support of these theories is described and the conceptual strengths and shortcomings of each approach are considered. It is argued that each of these approaches adds to the understanding of unexplained illness but that none is able to provide a comprehensive explanation of the phenomenon. An integrative conceptual model of unexplained illness based on cognitive psychological principles is then presented. This model attempts to combine existing theoretical approaches within a single explanatory framework, extending previous theory by explaining how compelling symptoms can exist in the absence of organic pathology. The clinical and empirical implications of the model are then considered.     

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.     

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.     

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.     

Experience of agency and sense of responsibility

The experience of agency refers to the feeling that we control our own actions, and through them the outside world. In many contexts, sense of agency has strong implications for moral responsibility. For example, a sense of agency may allow people to choose between right and wrong actions, either immediately, or on subsequent occasions through learning about the moral consequences of their actions. In this study we investigate the relation between the experience of operant action, and responsibility for action outcomes using the intentional binding effect (Haggard, Clark, & Kalogeras, 2002) as an implicit, quantitative measure related to sense of agency. We studied the time at which people perceived simple manual actions and their effects, when these actions were embedded in scenarios where their actions had unpredictable consequences that could be either moral or merely economic. We found an enhanced binding of effects back towards the actions that caused them, implying an enhanced sense of agency, in moral compared to non-moral contexts. We also found stronger binding for effects with severely negative, compared to moderately negative, values. A tight temporal association between action and effect may be a low-level phenomenal marker of the sense of responsibility.     

Subjectivity and environmental influence in relation to sense of authenticity

The authors responded to criticisms raised recently by Giannini (2010) of the authors' 2009 study in which cross-age differences were examined in the sense of authenticity. Comments address three aspects of the criticism, interpretation of the results, and misunderstanding of the method used as well as the concepts. In particular, future research likely needs to focus on the subjective aspects of sense of authenticity.     

Emotional valence,sense of agency and responsibility: A study using intentional binding

We investigated how the emotional valence of an action outcome influences the experience of control, in an intentional binding experiment. Voluntary actions were followed by emotionally positive or negative human vocalisations, or by neutral tones. We used mental chronometry to measure a retrospective component of sense of agency (SoA), triggered by the occurrence of the action outcome, and a prospective component, driven by the expectation that the outcome will occur. Positive outcomes enhanced the retrospective component of SoA, but only when both occurrence and the valence of the outcome were unexpected. When the valence of outcomes was blocked – and therefore predictable – we found a prospective component of SoA when neutral tones were expected but did not actually occur. This prospective binding was absent, and reversed, for positive and negative expected outcomes. Emotional expectation counteracts the prospective component of SoA, suggesting a distancing effect.     

Making sense of ourselves: self-narratives and personal identity

Some philosophers take personal identity to be a matter of self-narrative. I argue, to the contrary, that self-narrative views cannot stand alone as views of personal (or numerical) identity. First, I consider Dennett’s self-narrative view, according to which selves are fictional characters—abstractions, like centers of gravity—generated by brains. Neural activity is to be interpreted from the intentional stance as producing a story. I argue that this is implausible. The inadequacy is masked by Dennett’s ambiguous use of ‘us’: sometimes ‘us’ refers to real human beings, and sometimes ‘us’ refers to selves or fictional characters. Second, I consider Schechtmann’s view that self-narratives create persons (in the sense that she calls ‘characterization’ or personality. I argue that the sense in which a self-narrative creates a person cannot stand on its own: a person must already exist (in the sense of numerical identity) in order for there to be a self-narrative. Finally, I offer my own account of persons.     

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.     

School shootings: Making sense of the senseless

School shootings have altered the patina of seclusion and safety that once characterized public and higher education. Callous and brutal, school shootings seem to make no sense. However, case comparisons and anecdotal reports are beginning to show patterns that provide clues for understanding both the individual factors motivating shooting events and the characteristics of schools where shootings have occurred. We describe these factors and characteristics as the bases for six prevention strategies: (a) strengthening school attachment, (b) reducing social aggression, (c) breaking down codes of silence, (d) establishing screening and intervention protocols for troubled and rejected students, (e) bolstering human and physical security, and (6) increasing communication within educational facilities and between educational facilities and local resources.     

Family narrative interaction and children's sense of self

Family narratives about the shared past may be a particularly significant site for preadolescents' emerging sense of self both as an individual and as a member of a unified family. We examined the relations between family narrative interaction style when reminiscing and preadolescents' sense of self. Results indicated three narrative interaction styles that describe the extent to which families discuss or fail to discuss their past in integrated and validating ways. Specifically, conversations with a coordinated perspective incorporated information from all members and were related to higher self-esteem, especially in girls. Conversations with an individual perspective, in which family members took turns telling their thoughts and feelings about the event without integration among the perspectives, were associated with a more external locus of control, especially in boys. Conversations with an imposed perspective, in which one family member was in charge of the conversation or in which unpleasant exchanges between members occurred, were not associated with either self-esteem or locus of control. Implications of these narrative interaction styles for children's developing sense of self are discussed.     

Harm inflation: Making sense of concept creep

ABSTRACT

“Concept creep” is the gradual semantic expansion of harm-related concepts such as bullying, mental disorder, prejudice, and trauma. This review presents a synopsis of relevant theoretical advances and empirical research findings on the phenomenon. It addresses three fundamental questions. First, it clarifies the characterisation of concept creep by refining its theoretical and historical dimensions and presenting studies investigating the change in harm-related concepts using computational linguistics. Second, it examines factors that have caused concept creep, including cultural shifts in sensitivity to harm, societal changes in the prevalence of harm, and intentional meaning changes engineered for political ends. Third, the paper develops an account of the consequences of concept creep, including social conflict, political polarisation, speech restrictions, victim identities, and progressive social change. This extended analysis of concept creep helps to understand its mixed implications and sets a multi-pronged agenda for future research on the topic.     

Making sense: The work of Eugene Gendlin

This and the following papers were presented at a symposium organized by David M. Levin honoring the work of Eugene Gendlin at meetings of the Society for Phenomenology and the Human Sciences, Boston, October, 1992.