Views of what's wrong: diagnosis and patients' concepts of illness

The language of compliance: health policy and clinical practice for the severely mentally ill

This paper appraises the issues surrounding 'compliance' from a biomedical and specifically psychiatric perspective with particular reference to the drug treatment of psychiatric patients and the influential factors in the development of health policy. I examine how existing conceptualisations fail to have a significant impact on the way people with severe mental illness (chronic disorders such as schizophrenia) interact with prescribed medication (usually neuroleptic) and explore what potential insights can be gleaned from the anthropological literature.

Opening Pandora's box: the unpredictability of reassurance by a normal test result

OBJECTIVES

To determine the rate of failure of patient reassurance after a normal test result and study the determinants of failure.

DESIGN

Replicated single case study with qualitative and quantitative data analysis.

SETTING

University teaching hospital.

SUBJECTS

40 consecutive patients referred for echocardiography either because of symptoms (10 patients) or because of a heart murmur (30). 39 were shown to have a normal heart.

INTERVENTIONS

Medical consultations and semistructured patient interviews were tape recorded. Structured interviews with consultant cardiologists were recorded in survey form.

MAIN OUTCOME MEASURES

Patient recall of the explanation and residual understanding, doubt, and anxiety about the heart after the test and post-test consultation.

RESULTS

All 10 patients presenting with symptoms were left with anxiety about the heart despite a normal test result and reassurance by the consultant. Of 28 patients referred because of a murmur but shown to have no heart abnormality, 20 became anxious after detection of the murmur; 11 had residual anxiety despite the normal test result.

CONCLUSIONS

Reassurance of the "worried well"-anxious patients with symptoms or patients concerned by a health query resulting from a routine medical examination or from screening-constitutes a large part of medical practice. It seems to be widely assumed that explaining that tests have shown no abnormality is enough to reassure. The results of this study refute this and emphasise the importance of personal and social factors as obstacles to reassurance.

Self rated health as a predictor of coronary heart disease in Copenhagen, Denmark

STUDY OBJECTIVE

To analyse the association between self rated health and the incidence of fatal and non-fatal coronary heart disease (CHD) in a Danish cohort followed up over 16 years.

DESIGN

This was a prospective epidemiological follow up study.

SETTING

A cohort from the County of Copenhagen, Denmark.

PARTICIPANTS

The study included 1052 men and women born in 1936. During the 16 years' follow up 50 cases of CHD were registered in either the Danish register of deaths or the register of hospital admissions.

MAIN RESULTS

Univariate analysis showed the following relative risks of CHD in the four self rated health groups: 'extremely good': 1.0, 'good': 4.0, 'poor': 5.8, 'miserable': 12.1 (p = 0.02). After control for the conventional CHD risk factors and a substantial number of other potential confounders the relative risks were: 1.0, 4.2, 6.5, and 18.6 (p = 0.02) respectively.

CONCLUSIONS

Self rated health was an independent predictor of CHD in the present cohort. If confirmed, the association between self rated health and CHD may lead to new insight into psychosocial processes leading to this disease.

Research implications for alternative health therapies

Nontraditional health practices have gained in popularity during the past 10-15 years. Unfortunately, the effectiveness of many nontraditional approaches have been inadequately investigated. Furthermore, tradition research protocols often have fallen short in providing satisfactory strategies for these types of investigations because the nature of the personal belief system between patient and provider has not been examined. The authors discuss the implications for triangulation techniques in nursing research related to nontraditional treatments. Six types of triangulation are defined and methods for utilizing these techniques are explained.

Objects, contradictions and collaboration in medical cognition: an activity-theoretical perspective

Activity theory suggests three principles for contextual analysis of clinical cognition: orientation to objects in cognition, role of contradictions in cognition, and the importance of collaboration in cognition. Focusing on the objects of cognition calls attention to differences across medical work settings. There is an interconnection between the type of the object encountered, the physician's generalized conception of the object, and the physician's choice of linearization or lateralization as cognitive strategy. In a consultation the object of medical cognition is locally constructed through a series of mediated actions. Identification of contradictions at the level of the institutional activity system is crucial for the understanding of failures and innovations in actions of medical cognition. A conceptual model for analyzing such contradictions is presented. It is demonstrated that medical cognition is a collaborative achievement between the physician and the patient. Patients use a variety of strategies to turn their experienced health problems into manageable problems. The patient's strategy can and often does influence the physician's strategy and the outcome of the consultation.

The impact of symptom interpretation on physician utilization

This article explores physician consultation decisions among a sample of elderly people living in community settings. The analysis integrates the insights of research on illness behavior, particularly symptom interpretation and lay consultation, with previous specifications of the Health Behavior Model. Data were gathered through personal interviews and health diaries completed on a daily basis for 21 consecutive days by a probability sample of older people living in community settings. Results indicate that uncertainty regarding potential seriousness, level of pain or interference, and causal attributions were the most consistently significant predictors of physician contact.

Opinions in Denmark on the causes of peptic ulcer disease. A survey among Danish physicians and patients

The aim of the study was to investigate opinions among Danish patients and physicians on causes of peptic ulcer disease. Fifty-nine patients with an ulcer history and 77 physicians with a special interest in gastroenterology participated. They were given a questionnaire listing 16 possible causes of peptic ulcer and indicated for each whether they believed it was a contributory cause of the disease. The patients stated 0-10 causes each (median, 4), and the physicians 3-12 causes (median, 6) (p < 0.01). Younger physicians stated more causes than did the older ones (p < 0.01), and female physicians stated more causes than did their male colleagues (p < 0.01). Seventy-five per cent of the patients indicated that psychologic factors, such as grief, anxiety, and stress, were contributory causes of peptic ulcer disease, whereas only around 40% believed that coffee/tea, alcohol, smoking, side effects of medicine, and working conditions played a causal role. Around 95% of the physicians indicated that medical drugs and smoking were contributory causes of peptic ulcer disease, and around 80% that alcohol and psychologic factors were so. Only 30-40% of the physicians believed that coffee/tea, food habits, infection, and working conditions could play a causal role in ulcer disease. It is concluded that the opinion on causal agents in peptic ulcer disease differ considerably among both patients and physicians. Opinions on causes of diseases may influence the way we treat and advise our patients, and attempts should thus be made to unify our knowledge and interpretations of causes of diseases to reach more solid ground in counselling our patients.

Lay evaluation of symptoms by older people: an assessment of potential risk

This paper examines the appropriateness of lay evaluations of potential risk of symptoms among a sample of 667 elderly people living in community settings. Data were gathered through personal interviews and 3 weeks of structured health diaries in which older respondents recorded the symptoms they experienced. Potential medical risk was determined on a symptom by symptom basis based on clinical information gathered during the interviews. Almost three fourths of the respondents exhibited potential clinical risk for at least one symptom they experienced during the 3-week diary period. One in eight respondents was judged at risk yet gave no evidence of physician consultation, either during or prior to the diary period. Implications of these results for health education designed to improve consultation decisions among elderly people are discussed.

Stress, anxiety and depression: women's accounts of their health problems

In a study of a stratified random sample of 356 Canadian women, stress, anxiety and depression were among the most frequently reported health problems. The first part of this paper outlines the different social characteristics of those who reported stress, anxiety and depression. Women experienced mental health problems differently depending on their socio-economic status, ethnicity, family structure, the quality of family relationships and the nature of their participation in the labour market. It is argued that we need a more detailed analysis of these aspects of women's estate if we are to understand the social production of mental health and variations between women. Subsequent sections of the paper discuss women's own understanding of the sources of their mental health problems. While they spoke of the particularities of their own lives, these were often located in the context of broader social influences. They emphasized the social aetiology of mental health, noting the importance of gender roles and images of women. They described the heavy workload of women, issues of identity and their social legacies. In conclusion, it is noted that women appear to normalize the mental health problems they report. This may, in part, reflect the lack of social reinforcement and validation of their experiences.

Parental responses to consanguinity and genetic disease in Saudi Arabia

In-depth interviews of 36 Saudi families whose children suffered from neuro-metabolic disorders were conducted at a specialist hospital in Riyadh in order to examine parental understanding of disease and attitudes towards future births and consanguineous marriages. Parents had difficulty accepting a genetic explanation for diseases that did not affect all children at the time of birth; they also expressed religious or folk beliefs to account for illness. Coping behaviours included denial and resignation to the situation, divorce and remarriage. Some families adopted a cautious approach to cousin marriages and future births; this was significantly related to their education level, but not to previous infant deaths. Awareness of medical facts brought little emotional comfort to parents but allowed for preventive measures through screening adult carriers and identifying affected infants. This study presents new material from Saudi Arabia to strengthen current awareness that the range of religious beliefs, social attitudes and reproductive behaviours adopted by families in a society undergoing rapid change is of direct relevance to health care.

The mundane ailment and the physical self: analysis of the social psychology of health and illness

Using interview data from adult men and women who participated in an ongoing study of self-care, the research focused on the experience of mundane ailments as a promising topic for research in the social psychology of health and illness. Phenomenological analysis of respondents' accounts of everyday ailments generated concepts of 'the physical self', which expands interactive or dramaturgical concepts, and 'the health biography'. These concepts, when linked to analysis of interaction lead to a more dynamic sociology of health, illness, care and cure.

Compliance and the patient's perspective: controlling symptoms in everyday life

Non-compliance with medical advice is poorly understood. Most of the existing literature considers the problem only from the doctor's point of view. We undertook a diachronic, qualitative study of the illness experiences of 19 women to try to understand non-compliance from the patient's perspective. Three-fourths of our study group had ceased to follow their doctor's recommendations by four months post-diagnosis. Their non-compliance could not be explained by the fact that the women held understandings of their illnesses which were incongruent with their physician's; nor were they unable to understand the diagnosis they received. A consideration of the roles that their diagnosis and treatments played in their daily lives proved more useful in explaining their failure to follow physicians' recommendations. Patients' use of treatments reflected their desire to control symptoms within the constraints of their daily routines.

Experiencing symptoms in chronic illness: fatigue in multiple sclerosis

This paper examines the various ways in which symptoms of chronic illness may be experienced. With particular reference to fatigue in multiple sclerosis, it discusses how the conceptualization of symptoms as discrete entities requiring targeted action (common in much current writing on chronic illness) is only one form in which physical disorder may be recognized by those directly affected, and one which probably applies little in the course of everyday life. The paper draws attention to the significance of personal and social context in symptom definition and to the implications for the measurement of symptoms and for advice to patients on management.