The classification and nomenclature of ‘medically unexplained symptoms’: Conflict, performativity and critique

Multimorbidity as chronic crisis: 'Living on' with multiple long-term health conditions in a socially disadvantaged London borough

Contemporary health services are primarily designed around single diseases. People with multimorbidity (multiple long-term health conditions) often become burdened by accumulated treatments. Through multimodal fieldwork in a socially disadvantaged London borough, we explore how people living with multimorbidity navigate conditions of 'chronic crisis', encompassing ill-health, overmedicalisation, polypharmacy and social exclusion. Participants in our study frequently experience 'existential stuckness', exacerbated by processes of social exclusion. We argue that diagnoses and treatments should account for people's unique aetiologies, and prioritise the notion of 'flourishing' over 'cure' as the absence of disease is not always achievable. To foster this emphasis on flourishing, we advocate for a dialogical turn in diagnostic processes that better support patients' existential needs in the context of long-term illness.

Diagnosing by anticipation: Coordinating patient trajectories within and across social systems

Anticipation is a fundamental aspect of social life and, following Weber, the hallmark of social action-it means trying to take others' responses to our actions into account when acting. In this article, we propose and argue the relevance of anticipation to the sociological study of diagnosis. To that end, we introduce and elaborate on the concept of diagnosing by anticipation. To diagnose by anticipation is to consider diagnoses as cultural objects imbued with meaning, to anticipate how others will respond to their meaning in situ and to adapt the choice of diagnosis to secure a desired outcome. Unlike prognosis, which seeks to predict the development of a disease, diagnosing by anticipation entails seeking to predict the development of a case and the effect of different diagnostic categories on its trajectory. Analytically, diagnosing by anticipation therefore involves a shift in diagnostic footing, from trying to identify what the case is a case of, to trying to identify which diagnosis will yield the desired case trajectory. This shift also implies a stronger focus on the mundane organisational work of operating diagnostic systems and coordinating case trajectories within and across social systems, to the benefit of the sociology of diagnosis.

Meaning and role of functional-organic distinction: a study of clinicians in psychiatry and neurology services

The functional-organic distinction attempts to differentiate disorders with diagnosable biological causes from those without and is a central axis on which diagnoses, medical specialities and services are organised. Previous studies report poor agreement between clinicians regarding the meanings of the terms and the conditions to which they apply, as well as noting value-laden implications of relevant diagnoses. Consequently, we aimed to understand how clinicians working in psychiatry and neurology services navigate the functional-organic distinction in their work. Twenty clinicians (10 physicians, 10 psychologists) working in psychiatry and neurology services participated in semistructured interviews that were analysed applying a constructivist grounded theory approach. The distinction was described as often incongruent with how clinicians conceptualise patients' problems. Organic factors were considered to be objective, unambiguously identifiable and clearly causative, whereas functional causes were invisible and to be hypothesised through thinking and conversation. Contextual factors-including cultural assumptions, service demands, patient needs and colleagues' views-were key in how the distinction was deployed in practice. The distinction was considered theoretically unsatisfactory, eventually to be superseded, but clinical decision making required it to be used strategically. These uses included helping communicate medical problems, navigating services, hiding meaning by making psychological explanations more palatable, tackling stigma, giving hope, and giving access to illness identity. Clinicians cited moral issues at both individual and societal levels as integral to the conceptual basis and deployment of the functional-organic distinction and described actively navigating these as part of their work. There was a considerable distance between the status of the functional-organic distinction as a sound theoretical concept generalisable across conditions and its role as a gatekeeping tool within the structures of healthcare. Ambiguity and contradictions were considered as both obstacles and benefits when deployed in practice and strategic considerations were important in deciding which to lean on.

Acquiring a new understanding of illness and agency: a narrative study of recovering from chronic fatigue syndrome

BACKGROUND

The condition known as chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is poorly understood. Simplified medical models tend to neglect the complexity of illness, contributing to a terrain of uncertainty, dilemmas and predicaments. However, despite pessimistic pictures of no cure and poor prognosis, some patients recover.

PURPOSE

This study's purpose is to provide insight into people's experiences of suffering and recovery from very severe CFS/ME and illuminate understanding of how and why changes became possible.

METHODS

Fourteen former patients were interviewed about their experiences of returning to health. A narrative analysis was undertaken to explore participants' experiences and understandings. We present the result through one participant's story.

RESULTS

The analysis yielded a common plotline with a distinct turning point. Participants went through a profound narrative shift, change in mindset and subsequent long-time work to actively pursue their own healing. Their narrative understandings of being helpless victims of disease were replaced by a more complex view of causality and illness and a new sense of self-agency developed.

DISCUSSION

We discuss the illness narratives in relation to the disease model and its shortcomings, the different voices dominating the stories at different times in a clinically, conceptually, and emotionally challenging area.

A Dutch Study of Remarkable Recoveries After Prayer: How to Deal with Uncertainties of Explanation

This article addresses cases of remarkable recoveries related to healing after prayer. We sought to investigate how people who experienced remarkable recoveries re-construct and give meaning to these experiences, and examine the role that epistemic frameworks available to them, play in this process. Basing ourselves on horizontal epistemology and using grounded theory, we conducted this qualitative empirical research in the Netherlands in 2016-2021. It draws on 14 in-depth interviews. These 14 cases were selected from a group of 27 cases, which were evaluated by a medical assessment team at the Amsterdam University Medical Centre. Each of the participants had experienced a remarkable recovery during or after prayer. The analysis of the interviews, which is based on the grounded theory approach, resulted in three overarching themes, placing possible explanations of the recoveries within (1) the medical discourse, (2) biographical discourse, and (3) a discourse of spiritual and religious transformation. Juxtaposition of these explanatory frameworks provides a way to understand better the transformative experience that underlies remarkable recoveries. Uncertainty regarding an explanation is a component of knowing and can facilitate a dialogue between various domains of knowledge.

A Theoretically Informed Critical Review of Research Applying the Concept of Liminality to Understand Experiences with Cancer: Implications for a New Oncological Agenda in Health Psychology

Liminality was described more than 20 years ago as a major category explaining how cancer is experienced. Since then, it has been widely used in the field of oncology research, particularly by those using qualitative methods to study patient experience. This body of work has great potential to illuminate the subjective dimensions of life and death with cancer. However, the review also reveals a tendency for sporadic and opportunistic applications of the concept of liminality. Rather than being developed in a systematic way, liminality theory is being recurrently 're-discovered' in relatively isolated studies, mostly within the realm of qualitative studies of 'patient experience'. This limits the capacity of this approach to influence oncological theory and practice. In providing a theoretically informed critical review of liminality literature in the field of oncology, this paper proposes ways of systematizing liminality research in line with a processual ontology. In so doing, it argues for a closer engagement with the source theory and data, and with more recent liminality theory, and it sketches the broad epistemological consequences and applications.

Contesting misrecognition online: Experiences of epistemic in/justice by vloggers with contested illnesses

Contested illnesses, such as fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and chronic Lyme disease (CLD), are surrounded by polemic debates regarding their etiology, symptomology, treatment, and even their existence. People who suffer from these contested illnesses arguably also suffer from "epistemic injustice." This concept, coined by the philosopher Miranda Fricker, captures how people's knowledge may be discredited because of identity prejudices. In our paper, this concept is used to understand how seven Dutch women with contested illnesses experience the emancipatory potential of their vlogging practices. Our findings show how these women understood their vlogging as a means to break with epistemic smothering, understood as the propensity to cater ones testimony to one's audience (Dotson, 2011), and as a means to attain and enhance epistemic justice. However, our findings also show how vlogging about contested illnesses did not seem to allow these women to fully break with their epistemic smothering practices, and that the ableist design and gendered norms of YouTube were experienced as obstacles to attaining epistemic justice. We conclude that, even though social media do seem to hold emancipatory potential for these women, the experiences of individual users are diverse and ambiguous.

The social representations of diagnosing Lyme disease

Social science studies on the controversy surrounding Lyme disease (LD) focused on the opposition between the "mainstream" and biomedical approach on one side and the "Lyme-literate" one on the other side, the latter claiming the existence of the chronic form of LD. The qualitative and exploratory study 'C18-48 Quali-Explo-PIQTIQ' (2019) investigated the social representations of LD in patients bitten by a tick. Twenty-four semi-structured interviews were conducted in three French medical units. Thematic and patient trajectory analyses were performed. Our results showed that, after the tick bite, some patients presented an "illness without disease" condition, characterised by uncertainty. In some cases, they consulted "Lyme-literate" health providers and received a diagnosis of chronic LD. This diagnosis was obtained by prescribing unassessed biological testing, providing an objective result and clinical categorisation. Unlike literature on the "Lyme-literate" approach, this diagnostic procedure involved some biomedical operations.

Micropolitics of Rare Diseases in Italy

Many stakeholders are involved in knowledge production regarding rare diseases. However, disputes and contentions can arise in this field. In this article, I analyze how professionals and afflicted people mobilized the category of "rare diseases" within a hospital center in Italy. By exploring the micropolitics performed there, I observe how practitioners produced inclusion in the Italian health care system or exclusion from it. I then show how users of the health care service challenged such practices, through their own interpretations of "rare diseases," while even the refusal to participate in patients' organizations emerged sometimes as a form of resistance.

(Dis)respect and shame in the context of 'medically unexplained' illness

A significant proportion of somatic symptoms remain, at present, medically unexplained. These symptoms are common, can affect any part of the body, and can result in a wide range of outcomes-from a minor, transient inconvenience to severe, chronic disability-but medical testing reveals no observable pathology. This paper explores two first-person accounts of so-called 'medically unexplained' illness: one that is published in a memoir, and the other produced during a semi-structured interview. Both texts are revelatory for their expression of shame in the context of encountering disrespect from healthcare professionals. The first section of my paper, clinical encounters, explores disrespect which, I argue, takes three interconnecting forms in these texts: disrespect for pain when it is seen as 'medically unexplained', disrespect for the patient's account of her own pain, and disrespect for the patient herself. The second section elucidates the shame that occurs as an affective and embodied consequence of encountering such disrespect. I claim that patients living with so-called 'medically unexplained' illnesses suffer a double burden. They endure both somatic and social suffering-not only their symptoms, but also disrespectful, traumatic and shame-inducing experiences of healthcare systems. I conclude with a reflection on the urgent need for changes in clinical training that could improve the quality of life for these patients, even in the absence of an explanation, treatment or cure for their symptoms.

'If it can't be coded, it doesn't exist'. A historical-philosophical analysis of the new ICD-11 classification of chronic pain

Chronic pain entails a large burden of disease and high social costs, but is seldom 'in the picture' and barely understood. Until recently, it was not systematically classified but instead viewed as a symptom or sign. In the new International Classification of Diseases, (ICD)-11, to be implemented in 2022, 'chronic' pain is now classified as a separate disease category and, to a certain extent, approached as a 'disease in its own right'. Reasons that have been given for this are not based so much on new scientific insights, but are rather of pragmatic nature. To explore the background of these recent changes in definition and classification of chronic pain, this paper provides a historical-philosophical analysis. By sketching a brief history of how pain experts have been working on the definition and taxonomy since the 1970s, we demonstrate the various social and practical functions that underlie the new ICD-11 classification of chronic pain. Building on this historical-empirical basis, we discuss philosophical issues regarding defining and classifying chronic pain, in particular performativity and pragmatism, and discuss their implications for the broader philosophical debate on health and disease.

Searching for diagnostic certainty, governing risk: Patients' ambivalent experiences of medical testing

Diagnosis is pivotal to medicine's epistemic system: it serves to explain individual symptoms, classify them into recognizable conditions and determine their prognosis and treatment. Medical tests, or investigative procedures for detecting and monitoring disease, play a central role in diagnosis. While testing promises diagnostic certainty or a definitive risk assessment, it often produces uncertainties and new questions which call for yet further tests. In short, testing, regardless of its specific application, is imbued with meaning and emotionally fraught. In this article, we explore individuals' ambivalent experiences of testing as they search for diagnostic certainty, and the anxieties and frustrations of those for whom it remains elusive. Combining insights from sociological work on ambivalence and the biopolitics of health, and drawing on qualitative interviews with Australian healthcare recipients who have undergone testing in the context of clinical practice, we argue that these experiences are explicable in light of the contradictory impulses and tensions associated with what we term 'bio-subjectification'. We consider the implications of our analysis in light of the development of new tests that produce ever finer delineations between healthy and diseased populations, concluding that their use will likely multiply uncertainties and heighten rather than lessen anxieties.

Alien Guts? Exploring Lives of and with Irritable Bowels in Denmark

Irritable bowel syndrome (IBS) is a health challenge in Denmark, especially among young and middle-aged people. It raises questions about control, alienation, responsiveness, and responsibility in relation to the body in welfare societies. Based on long-term ethnographic fieldwork, this article explores how young and middle-aged Danes diagnosed with IBS inhabit and relate to their bodies. Previous studies have described how IBS patients experience their bodies to be unreliable, unpredictable, and embarrassing. Drawing on phenomenological explorations of bodily alterity, we argue that the gut transforms into "an other" for the afflicted. It is involved in a restless process in which it sometimes emerges as "me," sometimes as "not-me," and sometimes as "not-not-me." People attempt to theorize and control their gut trouble, yet it continuously escapes their grasp. How do people live with and care for such an alienness-within? Does an IBS diagnosis make bodies feel more or less alien?

"Old friend and powerful cadre": Doctor-patient relationships and multi-dimensional therapeutic landscapes in China's primary hospitals

A positive doctor-patient relationship is believed to play a key role in the healing process in clinics. While challenges to the doctor-patient relationship are a global concern, complex social contexts which introduce familial collectivism and totalitarian bureaucracy to maintain a doctor's authority have complicated doctor-patient relationships in China. This study delineates a multi-dimensional therapeutic landscape of hospitals in China, focusing on the doctor-patient relationship performances used to improve patients' healing experiences. Based on fieldwork in two primary hospitals in Eastern China, we find that primary hospitals in China are not only professional spaces, but hybrids of professional and non-professional spaces. In these spaces, both professional and other discourses in various forms of social-environmental engagement affect therapeutic experiences. Varying time and space in hospitals allow doctors to construct multi-dimensional therapeutic landscapes vis-a-vis patients to secure patients' compliance with their recommendations, and thus improve health outcomes. We argue that these dimensions may also cause negative therapeutic experience such as unnecessary health care. This study contributes to the literature on therapeutic landscapes of health care by providing a critical view on the construction of multi-dimensional therapeutic hospital landscapes. Furthermore, it links the critical health geographies literature with China's broader social context to explicate the cultural and social transformation of health care spaces in contemporary China. Findings from this study inform both theoretical and empirical debates regarding therapeutic landscapes of health care by embedding the professional spaces of health care into broader geographical discourses. This calls for health professionals to reflect on ethical concerns in multi-dimensional health care landscapes.

Successful Psychological Strategies of Experienced Chronic Fatigue Patients: A Qualitative Study

Trying to care for patients with medically unexplained symptoms (MUS) can lead to frustration and disappointment for both patients and health care professionals alike. Learning positive ways to assist patients avoids professionals collapsing into therapeutic nihilism. We sought to understand how people with such symptoms can live well despite (or even because of) their condition. Chronic fatigue was chosen as the exemplar symptom. Participants were invited to join the research if they, themselves, considered they were living well with this symptom. One-on-one interviews using an appreciative enquiry approach were performed and thematic analysis undertaken. Twelve participants were interviewed before data saturation occurred. The emotional stance or relationship a participant had with, and towards, their illness was the primary determinant underlying their interpretation of “living well.” Five major themes of this meta-theme were identified: (1) engaging with elusiveness, (2) befriending uncertainty, (3) reflecting on self, (4) living creatively, and (5) moving in stillness. Encouraging patients who are struggling with MUS to consider how they emotionally engage with their illness via these 5 positive dynamics may lead to better health outcomes for patients and happier, more fulfilled health care professionals.

Symptom attribution to a medically unexplained syndrome is associated with greater perceived severity and bothersomeness of symptoms in US military veterans

OBJECTIVE

Medically unexplained symptoms (MUS) are prevalent among veteran and non-veteran populations. Current biopsychosocial theory implicates a multitude of factors in MUS development and perpetuation. The current study tests whether physical symptom attribution to MUS is associated with perceived symptom severity and bothersomeness and thereby might function to perpetuate MUS, as suggested by existing theory.

DESIGN AND MAIN OUTCOME MEASURES

Military combat veterans (n = 243) answered postal-mail questions about their physical symptoms, severity of experienced symptoms, and attributions of these symptoms to MUS (e.g. Gulf War Illness) versus non-MUS conditions.

RESULTS

Independent t-tests showed support for the first hypothesis-that those who experience the symptom and attribute it to MUS will perceive it to be more severe and bothersome than those who experience the symptom but do not attribute it to MUS. Paired-sample t-tests showed support for the second hypothesis-that experienced symptoms attributed to MUS by an individual will be perceived as more severe and bothersome than experienced symptoms the individual does not attribute to MUS.

CONCLUSIONS

Results highlight a potential role of symptom attribution in MUS perpetuation, through greater perceived severity and bothersomeness of MUS-attributed symptoms. Possible intervention targets may include behavior ramifications, such as coping strategies; more research is needed.

Narrative reconstruction of mental illness as a work-stress-induced disorder: Processes, consequences and implications

Stress-induced mental illnesses have become the focus of increasing international attention, particularly in Japan since the 1990s, where judiciary cases and welfare-state initiatives established causal links between work stress and mental illness. However, how individuals retrospectively construct this causality remains a marginal topic in the literature. This ethnographic article explores the ways in which male workers seeking compensation for their condition (depression and adjustment disorder) reconstruct aetiology narratives and to what avail. This paper demonstrates two themes: (1) how objectivising stress (related to specific formats of worker compensation), no-faulting (dispensing with individual blame to view stress as pervasive in the workplace) and negotiating blame (seeking explanation in terms of individual psychology) construct a case, and (2) how narrative reconstruction functions as both a barrier to recovery and way of working towards recovery and collective function. It is argued that the narrative reconstructions of workers, who become unwell and seek recognition, suggest uncertain self-victimisation despite the broader understanding of mental illness in contemporary Japan. The findings imply the heuristic potential of relativising causality and treating analytical dichotomies, including causality-narrative, victimhood-agency and fact-fiction, not as contradictory alternatives, but as different analysis levels, to better understand ambiguous illness narratives.

What do patients prefer their functional seizures to be called, and what are their experiences of diagnosis? - A mixed methods investigation

This study explored the preferred terms for functional seizures, and the experience of being diagnosed, from the patient's perspective. 39 patients in a neuropsychiatry service diagnosed with functional seizures completed an online survey to investigate preferences for, and offensiveness of, 11 common diagnostic terms used to describe functional seizures. Of these 39 patients, 13 consented to take part in a semistructured interview exploring the experience of receiving a diagnosis. Nonepileptic attack disorder (NEAD), functional seizures, functional nonepileptic attacks (FNEA), and dissociative seizures were ranked the highest preferred terms and did not significantly differ from one another. NEAD was the least offensive term, with functional seizures and FNEA following closely. Significant overlap in confidence intervals was found between the offensiveness of all terms. Terms that indicated a psychological origin were the least preferred and viewed as most offensive. Thematic analysis identified three main themes on the experience of being diagnosed: 'being heard and having a shared understanding', 'feeling alone', and 'sense of hope'. Patients favored diagnostic terms that facilitated and alleviated these themes on a personal basis; however, preferences differed across individuals. Our findings suggest that a range of terms have a similar level of preference and offense rating, with NEAD, functional seizures, and FNEA being the most favorable. Qualitative analysis indicates that a term and its accompanying explanation should facilitate shared acceptance and understanding, and several terms provide this. In combination with our previous study on healthy participants, we propose that one of the two terms researched are adopted by patients, health professionals, and the public: Functional nonepileptic attacks or Functional seizures.

Barriers and facilitators to the implementation of interventions for medically unexplained symptoms in primary care: A modified Delphi study

OBJECTIVE

Medically Unexplained Symptoms (MUS) are physical symptoms that last for longer than several weeks and for which no (sufficient) somatic explanation can be found. Interventions for treating MUS in primary care are available, but their implementation in daily practice appears difficult. In the current study we aim to explore key barriers and facilitators to the implementation of MUS-interventions in primary care.

METHODS

A three-round modified Delphi study was performed, using the input of 58 experts that are (in)directly involved in the care for patients with MUS (e.g. general practitioners (GPs), GP mental health workers, policy advisors). In the first online questionnaire, we generated ideas about relevant barriers and facilitators on different implementation levels. These ideas were independently coded by two researchers, and reformulated into unique barriers and facilitators. In round two, participants selected the ten most relevant barriers and facilitators from round one, which were ranked on importance in round three.

RESULTS

We identified 42 unique barriers and 57 unique facilitators to the implementation of MUS-interventions. The three highest ranked barriers were all related to time, i.e. too little time for treating complex MUS-patients. The most important facilitator was a positive attitude towards MUS-patients. Results varied somewhat per profession.

CONCLUSION

Key barriers and facilitators to the implementation of MUS-interventions seem to exist on the level of the patient, intervention, professional, organization, and external context. All of these levels should be taken into account in order to increase implementation success of MUS-interventions in primary care.

Making and managing medical anomalies: Exploring the classification of 'medically unexplained symptoms'

This article explores the making and management of anomaly in scientific work, taking 'medically unexplained symptoms' (MUS) as its case. MUS is a category used to characterize health conditions that are widely held to be ambiguous, in terms of their nature, causes and treatment. It has been suggested that MUS is a 'wastebasket diagnosis'. However, although a powerful metaphor, it does neither the category nor the profession justice: Unlike waste in a wastebasket, unexplained symptoms are not discarded but contained, not ejected but managed. Rather than a 'wastebasket', I propose that we instead think about it as a 'junk drawer'. A junk drawer is an ordering device whose function is the containment of things we want to keep but have nowhere else to put. Based on a critical document analysis of the research literature on MUS (107 research articles from 10 medical journals, published 2001-2016), the article explores how the MUS category is constituted and managed as a junk drawer in medical science.

Clearing the cobwebs: An analysis of the timing of youth concussion legislation in U.S. states

After decades of ignoring head injury in youth sports, U.S. states passed youth concussion legislation with stipulations about when athletes can return to play. Why were some states slower to pass laws than others? We consider this question through the lens of institutional medicalization, where medically informed policies are enacted. Our study recognizes the uneven nature of policy enactment across time and space with event history methods. We explore the influence of high school sport participation and other variables on the timing of legislation in all fifty states, 2007-2014. States with more high school football participation, as well as states with a strong college football presence, passed concussion laws later. Conversely, states with stronger orientations toward gender egalitarianism adopted laws sooner. These factors reflect sources of receptivity and resistance that underlie the process of institutional medicalization. Our approach offers one of the few quantitative studies of institutional medicalization and provides a template for future quantitative research in this area.

An investigation into the preferred terminology for functional seizures

There is considerable debate in the literature regarding what to call functional seizures, with terms such as pseudoseizures, nonepileptic attack disorder (NEAD), and dissociative seizures being used. Provision of an accurate diagnosis and coherent explanation is a vital first step in the management of functional seizures and can result in cessation or reduced frequency for some individuals. This study investigated preferences for and offensiveness of terms used to describe functional seizures, and expectations for recovery with psychological treatment. A sample of 87 healthy adults completed an online survey, in which eight different diagnostic terms were ranked in order of preference (1 - most preferred, 8 - least preferred): functional nonepileptic attacks (FNEA), dissociative seizures, functional seizures, psychogenic seizures, NEAD, pseudoseizures, conversion disorder, and hysteria. Replicating Stone and colleagues protocol, each term was investigated for five connotations. Offense scores were calculated from the number of participants who selected 'yes' to at least one of the negative connotations ('Putting it on', 'Mad', and 'Imagining Symptoms'). Expectations about the possibility of recovering through medical or psychological treatment were also recorded. Functional nonepileptic attack was ranked the highest preferred term with dissociative seizures and functional seizures closely following. Nonepileptic attack disorder was the least offensive term, with FNEA and functional seizures joint second. Unsurprisingly, the three least preferred terms were also the most offensive: pseudoseizures, conversion disorder, and hysteria. Expectations of nonrecovery from psychological treatment were lowest for terms implicating a psychological cause: pseudoseizures, dissociative seizures, psychogenic seizures, and hysteria. The results suggest that either the terms FNEA or functional seizures should be adopted by healthcare professionals and patients, as they are the most preferred, least offensive, and expectations for nonrecovery with psychological treatment were moderate compared with the other terms. Limitations and areas for future research are discussed.

What is the functional/organic distinction actually doing in psychiatry and neurology?

The functional-organic distinction aims to distinguish symptoms, signs, and syndromes that can be explained by diagnosable biological changes, from those that cannot. The distinction is central to clinical practice and is a key organising principle in diagnostic systems. Following a pragmatist approach that examines meaning through use, we examine how the functional-organic distinction is deployed and conceptualised in psychiatry and neurology. We note that the conceptual scope of the terms 'functional' and 'organic' varies considerably by context. Techniques for differentially diagnosing 'functional' and 'organic' diverge in the strength of evidence they produce as a necessary function of the syndrome in question. Clinicians do not agree on the meaning of the terms and report using them strategically. The distinction often relies on an implied model of 'zero sum' causality and encourages classification of syndromes into discrete 'functional' and 'organic' versions. Although this clearly applies in some instances, this is often in contrast to our best scientific understanding of neuropsychiatric disorders as arising from a dynamic interaction between personal, social and neuropathological factors. We also note 'functional' and 'organic' have loaded social meanings, creating the potential for social disempowerment. Given this, we argue for a better understanding of how strategic simplification and complex scientific reality limit each other in neuropsychiatric thinking. We also note that the contribution of people who experience the interaction between 'functional' and 'organic' factors has rarely informed the validity of this distinction and the dilemmas arising from it, and we highlight this as a research priority.

Illness perceptions of youths with functional disorders and their parents: An interpretative phenomenological analysis study

BACKGROUND

Functional disorders, defined as disorders with no clear medical explanation, are common and impose a significant burden on youths, their families, healthcare services and society as a whole. Currently, the literature describes resistance among patients and their families towards psychological symptom explanations and treatments. More knowledge about the thoughts and understandings of youths with functional disorders and their parents is needed. The aim of this study was to explore the illness perceptions of youths with severe functional disorders and their parents.

METHODS

A qualitative interview study using interpretative phenomenological analyses. The study included 11 youths aged 11-15 years with functional disorders and their parents, where interviews were performed at the point of referral from a somatic to a psychiatric treatment setting.

RESULTS

Analyses identified three main themes. Themes 1(Ascribing identity to the disorder) and 2 (Monocausal explanations) explore key elements of the participants' illness perceptions, and theme 3 (Mutable illness perceptions) explores how illness perceptions are influenced by experiences from healthcare encounters.

CONCLUSIONS

The label 'functional disorder' was poorly integrated in the illness perceptions of the youths and their parents. Participants used a monocausal and typically physical explanation rather than a multicausal biopsychosocial explanation for their symptoms.

Lyme Disease and the Epistemic Tensions of "Medically Unexplained Illnesses"

In the US, disagreement over the biological basis of "chronic Lyme disease" has resulted in the institutionalization of two standards of care: "mainstream" and "Lyme-literate." For mainstream physicians, chronic Lyme disease is a "medically unexplained illness" that presents with an abundance of "symptoms" in the absence of diagnostic "signs." For Lyme-literate physicians, and complementary and alternative medicine practitioners more generally, symptoms alone provide sufficient evidence for medical explanation. Drawing upon ethnographic research among mainstream and Lyme-literate physicians, I suggest that medically unexplained illness is not a biomedical anomaly but an intrinsic feature of biomedicine.

Naked in the eyes of the public: A phenomenological study of the lived experience of suffering from burnout while waiting for recognition to be ill

Although there has been a focus on problematic issues related to health care services and complaints made by patients, individuals who suffer from medically unexplained syndromes continue to report being epistemically marginalized or excluded by health professionals. The aim of this article is to uncover a deeper understanding of the what-ness of experiencing being naked in the eyes of the public while waiting to be recognized as ill. Therefore, a phenomenological approach was chosen to inductively and holistically understand the human experience in this context-specific setting. Semi-structured interviews were conducted with two men and six women between 25 and 65 years of age, who had been on sick leave for more than 52 weeks. Their symptoms were consistent with Exhaustion Disorder (ICD-10, F43.8A). The meaning of the interviewees' lived experience was explored using a life-world approach to phenomenological reflection and writing. The participants described their experience of encountering the general practitioner as taking part in a battle. Feeling distrusted by others seemed to result in disconnection from their habitual lifeworld, which in turn triggered a shame reaction. Additionally, the study showed a possible distrust related to several communication levels within the health care system, which influenced the recovery process negatively. Lack of experienced support can lead to exacerbated feelings of distress. Accordingly, the psychosocial experience of being ill might be as important as its unknown aetiology. Therefore, in the context of these interpersonal relations, both norms, values, and attitudes, and issues of power need to be considered and addressed properly.

Careful expressions of social aspects: How local professionals in high school settings, municipal services, and general practice communicate care to youth presenting persistent bodily complaints

Persistent health complaints pose communicative dilemmas in care encounters, adversely affecting patient experiences and pathways. Little is known about the impact and role of professionals in encounters with young people with incipient, debilitating, and persistent symptoms. This study aims to explore communicative dilemmas and the role of language in care provided by local professionals in high school settings, municipal services, and general practice to young people presenting persistent bodily complaints. The study is based on in-depth individual interviews conducted from April to July 2016 with 12 professionals identified and selected during anthropological multi-sited fieldwork in a Norwegian community. We identify two modalities of what we have chosen to call 'careful expression', used as strategies across professions to overcome communicative dilemmas. Professionals reflexively and pragmatically negotiated with the powers of language to influence illness experience and to enact empowered young subjects. These insights may prove relevant for future studies of care encounters while also indicating a critical attitude to institutional logics that affect care responses.

Heterodox and Orthodox Discourses in the Case of Lyme Disease: A Synthesis of Arguments

In this article, we examine the arguments made by authors of published academic articles concerning the debates surrounding chronic Lyme disease (CLD). CLD is an example of a contested condition and shares problems of legitimacy with other medically unexplained conditions such as chronic fatigue syndrome. We use a critical discourse analysis (CDA) approach to understand the arguments of the authors to establish the legitimacy, or not, of a CLD diagnosis. This enabled us to make sense of the nature of the stalemate between patient groups and advocates of the medical establishment, as performed by authors of academic articles. In this article, we bring together the arguments to explain the polemical debate and to support accounts that avoid the impasse to give us greater insight into the experience of chronic illness.

Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them

Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.

Opinion paper: the role of work in the management of medically unexplained physical symptoms

OBJECTIVES

Patients with medically unexplained physical symptoms suffer from chronic fatigue and/or pain in combination with a variety of other symptoms. A flexible, biopsychosocial approach is needed for diagnostic screening and global management. It is crucial to involve the direct patient environment, including family, friends, colleagues as well as health providers, evaluation, and reintegration sector. The aim of this paper is to review the importance of work in the management of medically unexplained physical symptoms.

METHODS

In this paper, different actors involved explain their views and handling concerning work in the management of MUPS.

RESULTS

Symptom severity and lack of understanding from the environment can negatively impact on earning an independent income from labor for years. Work, whether or not paid, is however, an important life domain with positive effects on physical, psychological, and social well-being. Therefore, health actors are pivotal in starting the professional reintegration process as soon as possible and should discuss this item from the early stage onward. Support services can be consulted in mutual interaction as required. A case manager, acting as a central intermediator within this multidisciplinary approach, may promote effective communication and coordination between the patients and their surrounding actors.

CONCLUSION

The professional reintegration process should start as soon as possible within the management of medically unexplained physical symptoms. As such, the care sector, the evaluation sector, and the professional integration sector should collaborate and effectively communicate with each other.

The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: A meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis aimed to update and give an overview of the evidence from published literature that focused on the efficacy of cognitive behaviour therapy (CBT) in the management of somatoform disorders and medically unexplained physical symptoms (MUPS).

METHODS

A comprehensive literature search was carried out through an electronic search of various databases on randomized controlled trials (RCTs). Primary outcome was the severity of somatic symptoms. Secondary outcomes were also measured based on severity of anxiety symptoms, severity of depressive symptoms, social functioning, physical functioning, doctor visits and the compliance with CBT, as well as follow-up visits. Effects were summarized by a random effects model using mean differences or odds ratio with 95% confidence intervals (CIs).

RESULTS

A total of 15 RCTs comprising 1671 patients with somatoform disorders or MUPS were enrolled in our systematic review and meta-analysis. The main analysis revealed that CBT could alleviate somatic symptoms: -1.31 (95% CI: -2.23 to -0.39, p = 0.005); anxiety symptoms: -1.89 (95% CI: -2.91 to -0.86; p < 0.001); depressive symptoms: -1.93 (95% CI: -3.56 to -0.31; p = 0.020); improve physical functioning: 4.19 (95% CI: 1.90 to 6.49; p < 0.001). The efficacy of CBT on alleviating somatic symptoms, anxiety and depressive symptoms were sustained on follow-up. CBT may not be effective in reducing the number of doctor visits: -1.23 (95% CI: -2.97 to 0.51; p = 0.166); and improving social functioning: 3.27 (95% CI: -0.08 to 6.63; p = 0.056). The results of subgroup analysis indicated that CBT was particularly beneficial when the duration of session was more than 50 min to reduce the severity of somatic symptoms from pre to post treatment time, when it was group based and applied affective and developed good interpersonal strategy during the treatment. Longer duration and frequency such as more than 10 sessions and 12 weeks treatments had significant effect on reduction of the comorbid symptoms including depression and anxiety, but they may underpin low level of compliance of CBT based treatments.

CONCLUSIONS

CBT is effective for the treatment of somatoform disorders and MUPS by reducing physical symptoms, psychological distress and disability.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms

BACKGROUND

Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS.

METHODS

Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes.

RESULTS

The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful.

CONCLUSIONS

Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Suboptimal health status and psychological symptoms among Chinese college students: a perspective of predictive, preventive and personalised health

Background

Suboptimal health status (SHS) is an intermediate health status between health and illness, a syndrome characterised by the perception of health complaints, general weakness and low energy. This study aimed to investigate the prevalence of SHS and the correlation between SHS and psychological symptoms among Chinese college students and to identify the SHS-related risk factors from the perspective of predictive, preventive and personalised medicine (PPPM).

Methods

A cross-sectional study was conducted among 4119 college students who were enrolled from Taishan Medical University and Baoji Vocational and Technical College in the eastern and western areas of China. SHS levels of the participants were measured by an established self-reporting Suboptimal Health Status Questionnaire-25 (SHSQ-25). Psychosomatic conditions were estimated by the self-rating Symptom Checklist-90 (SCL-90) scale. Spearman correlation analysis was applied to analyse the relationship between SHSQ-25 scores and SCL-90 estimates. Logistic regression analysis was applied for multivariate analysis.

Results

The prevalence of SHS was 21.0% (864/4119), with 23.3% (701/3005) for female students and 14.6% (163/1114) for male students. The prevalence of general positive psychological symptom was 14.2% (586/4119), with 15.6% (470/3005) for female students and 10.4% (116/1114) for male students. A strong correlation was identified between SHS score and SCL-90 estimates, with the correlation coefficient (r) of 0.719. Logistic regression showed that variables significantly associated with SHS were somatisation (adjusted odds ratio (aOR) = 3.185, 95% confidence interval [CI] = 2.048-4.953), obsessive-compulsive (aOR = 3.518, 95% CI = 2.834-4.368), interpersonal sensitivity (aOR = 1.883, 95% CI = 1.439-2.463) and depression (aOR = 1.847, 95% CI = 1.335-2.554).

Conclusions

Our findings confirm that there is a high prevalence of SHS among college students and there is a strong association between SHS and psychological symptoms among Chinese college students. High susceptibility of SHS occurs particularly in vulnerable groups: female students, sophomore students, medical students and students from rural area. Identification of SHS and prompt application of personalised psychological health-supporting activities will promote college students' health status.

In BMI We Trust: Reframing the Body Mass Index as a Measure of Health

Recent work in medical sociology has provided critical insights into distinguishing between obesity as a condition with severe individual- and population-level health consequences, and obesity as a socially undesirable, stigmatizing construct opposing thinness as the healthy ideal. Less often considered is the role of Body Mass Index (BMI) as the standard by which obesity and healthy weight are measured and defined. Addressing this issue, I begin by distinguishing between BMI as an empirical, objective measure of health, and BMI as an arbitrary, subjective label for categorizing the population. I further consider how BMI is empowered as a measurable quantity through the lens of medicalization and evidence-based medicine, and introduce the "performativity" of BMI as a superior framework for confronting the measure's conceptual limitations. Emphasizing key parallels between BMI and self-rated health as measures with high predictive validity, yet unspecified mechanisms of action, I propose an epistemological shift away from classifying BMI as a biomarker and toward a more flexible view of the measure as a holistic appraisal of health. In closing, I argue that researchers may continue to leverage BMI's ease of collection and interpretation, provided they are attuned to its definitional ambiguity across diverse research methods and contexts.

The biopolitics of CFS/ME

This paper argues that Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) constitutes a biopolitical problem, a scientific object which needs to be studied, classified and regulated. Assemblages of authorities, knowledges and techniques make CFS/ME subjects and shape their everyday conduct in an attempt to increase their supposed autonomy, wellbeing and health. CFS and CFS/ME identities are however made not only through government, scientific, and medical interventions but also by the patients themselves, a biosocial community who collaborates with scientists, educates itself about the intricacies of biomedicine, and contests psychiatric truth claims. CFS/ME is an illness trapped between medicine and psychology, an illness that is open to debate and therefore difficult to manage and standardise. The paper delineates different interventions by medicine, science, the state and the patients themselves and concludes that CFS/ME remains elusive, only partially standardised, in an on-going battle between all the different actors that want to define it for their own situated interests.

Personality traits such as neuroticism and disability predict psychological distress in medically unexplained symptoms: A three-year experience from a single centre

BACKGROUND

People with medically unexplained symptoms (MUS) may have psychological co-morbidities.

AIMS

Our objectives were to assess the rates and identify correlates of psychological distress in MUS.

METHODS

A total of 171 subjects with MUS seeking treatment at a tertiary care facility were assessed over a 3-year period. Psychological distress was assessed using the Tamil version of General Health Questionnaire-12. Apart from socio-demographic factors, personality, coping, perceived social support and subjective disability were assessed using standard instruments.

RESULTS

Ninety subjects (52.6%) endorsed symptoms of psychological distress. MUS subjects with psychological distress reported higher levels of neuroticism (p < 0.001), lower extraversion (p < 0.001), lower perceived social support (p = 0.002), higher disability (p < 0.001), lower problem focused engagement (p = 0.378) and higher emotion focused engagement (p = 0.009). In multivariate analysis, high neuroticism scores (odds ratio 1.579, 95% CI 1.108 to 2.251) and high disability (odds ratio 1.302, 95% CI 1.147 to 1.478) emerged as independent predictors of psychological distress in MUS.

CONCLUSION

More than half of subjects with MUS have associated psychological distress. High levels of neuroticism and disability are potential markers of psychological distress in MUS. Copyright © 2017 John Wiley & Sons, Ltd.

Balancing medical accuracy and diagnostic consequences: diagnosing medically unexplained symptoms in primary care

Focusing on the case of medically unexplained symptoms (MUS), this article explores diagnostic classification in the absence of biomedical evidence or other strong medical warrants for diagnosis. The data are from three focus group interviews with Norwegian general practitioners (GPs) conducted in 2015, that centred on the issue of what diagnoses to use (or not) for MUS. The qualitative analysis reconstructs the logic underlying GPs' diagnostic accounts, which centred on the meaning of diagnostic categories and on anticipating how 'generalised others' would respond to those meanings (called 'diagnosing by anticipation'). The analysis suggests that GPs confer diagnoses by balancing unwarranted medical accuracy and anticipated harmful diagnostic consequences; the goal of diagnosis was finding categories in the International Classification of Primary Care that would yield acceptable results, without making a liar of the GP in the process. Drawing on the distinction between diagnosis as colligation and classification, the findings and their relevance for medical sociology are discussed. Counter to frequent descriptions as 'illness that cannot be diagnosed', the analysis shows how GPs can diagnose MUS in the bureaucratic sense of diagnosis as classification - a sense that has been missing from sociological view.

High healthcare utilization near the onset of medically unexplained symptoms

OBJECTIVE

Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization.

METHODS

Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n=336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA).

RESULTS

Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope=-0.26, F=4.07, p=0.04), specialist (slope=-0.43, F=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope=-0.41, F=5.71, p=0.02) and mental health (slope=-0.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden.

CONCLUSION

This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

Motzkau J. Introduction to the Special Issue on Liminal Hotspots

This article introduces a special issue of Theory and Psychology on liminal hotspots. A liminal hotspot is an occasion during which people feel they are caught suspended in the circumstances of a transition that has become permanent. The liminal experiences of ambiguity and uncertainty that are typically at play in transitional circumstances acquire an enduring quality that can be described as a “hotspot”. Liminal hotspots are characterized by dynamics of paradox, paralysis, and polarization, but they also intensify the potential for pattern shift. The origins of the concept are described followed by an overview of the contributions to this special issue.

From paradox to pattern shift: Conceptualising liminal hotspots and their affective dynamics

This article introduces the concept of liminal hotspots as a specifically psychosocial and sociopsychological type of wicked problem, best addressed in a process-theoretical framework. A liminal hotspot is defined as an occasion characterised by the experience of being trapped in the interstitial dimension between different forms-of-process. The paper has two main aims. First, to articulate a nexus of concepts associated with liminal hotspots that together provide general analytic purchase on a wide range of problems concerning “troubled” becoming. Second, to provide concrete illustrations through examples drawn from the health domain. In the conclusion, we briefly indicate the sense in which liminal hotspots are part of broader and deeper historical processes associated with changing modes for the management and navigation of liminality.

Conversion disorder: A systematic review of current terminology

OBJECTIVE

It has been argued that the label given to unexplained neurological symptoms is an important contributor to their often poor acceptance, and there has been recent debate on proposals to change the name from conversion disorder. There have been multiple studies of layperson and clinician preference and this article aimed to review these.

DESIGN

Multiple databases were searched using terms including "conversion disorder" and "terminology", and relative preferences for the terms extracted.

RESULTS

Seven articles were found which looked at clinician or layperson preferences for terminology for unexplained neurological symptoms. Most neurologists favoured terms such as "functional" and "psychogenic", while laypeople were comfortable with "functional" but viewed "psychogenic" as more offensive; "non-epileptic/organic" was relatively popular with both groups.

CONCLUSIONS

"Functional" is a term that is relatively popular with both clinicians and the public. It also meets more of the other criteria proposed for an acceptable label than other popular terms - however the views of neither psychiatrists nor actual patients with the disorder were considered.

A taxonomy of explanations in a general practitioner clinic for patients with persistent "medically unexplained" physical symptoms

OBJECTIVE

To develop a taxonomy of explanations for patients with persistent physical symptoms.

METHODS

We analysed doctors' explanations from two studies of a moderately-intensive consultation intervention for patients with multiple, often "medically-unexplained," physical symptoms. We used a constant comparative method to develop a taxonomy which was then applied to all verbatim explanations.

RESULTS

We analysed 138 explanations provided by five general practitioners to 38 patients. The taxonomy comprised explanation types and explanation components. Three explanation types described the overall structure of the explanations: Rational Adaptive, Automatic Adaptive, and Complex. These differed in terms of who or what was given agency within the explanation. Three explanation components described the content of the explanation: Facts - generic statements about normal or dysfunctional processes; Causes - person-specific statements about proximal or distal causes for symptoms; Mechanisms - processes by which symptoms arise or persist in the individual. Most explanations conformed to one type and contained several components.

CONCLUSIONS

This novel taxonomy for classifying clinical explanations permits detailed classification of explanation types and content. Explanation types appear to carry different implications of agency.

PRACTICE IMPLICATIONS

The taxonomy is suitable for examining explanations and developing prototype explanatory scripts in both training and research settings.

An exploratory study of the experience of fibromyalgia diagnosis in South Africa

Within the conceptual framework of 'medically-ill-defined' conditions, this article focuses on the experiences of 'diagnosis' through a narrative analysis of fibromyalgia (a chronic musculoskeletal pain disorder) in South Africa. In-depth interviews were used to collect narratives from 15 participants. The findings show how the contested and confusing experience of fibromyalgia diagnosis can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The currency of fibromyalgia as a diagnosis and the inequalities present in the South African health care system characterise the experiences of symptom recognition, diagnosis and treatment. The analysis reveals how those living with fibromyalgia search for diagnosis, and struggle to maintain legitimacy for their experience in the complex constellation of porous symptoms that appear infrequently. The findings of this study confirm the existing evidence that shows fibromyalgia to be a challenging illness experience, which is attributed to the lack of clarity and legitimacy, and high contestation that surrounds the condition. Additionally, this study presents the ways that limited access to diagnosis and treatment for fibromyalgia in the South African context shapes this specific illness experience, and the value of using narrative approaches to gain insight into how people live with hidden and poorly understood conditions in this environment.

Work-Recreation Balance, Health-Promoting Lifestyles and Suboptimal Health Status in Southern China: A Cross-Sectional Study

Suboptimal health status (SHS)—an intermediate state between health and illness—refers to functional somatic symptoms that are medically undiagnosed. Although SHS has become a great challenge for global public health, very little about its etiology and mechanisms are known. Work-recreation balance is a part of work−life balance, and is related to stress which greatly influences health status. We therefore carried out a cross-sectional investigation between 2012 and 2013 within a clustered sample of 24,475 individuals aged 15−60 years from a population in southern China. In so doing, we hoped to illuminate the associations between work-recreation balance conditions, healthy lifestyles, and SHS. Work-recreation balance conditions were categorically defined by frequency (“rarely, sometimes, or always”). Health-Promoting Lifestyle Profile (HPLP-II) was used to evaluate the level of healthy lifestyles, and the medical examination report and Sub-Health Measurement Scale V1.0 (SHMS V1.0) were both used to evaluate health status. The ratio of SHS (46.3%) is higher than health status (18.4%) or disease status (35.3%). Overall, 4.9% of respondents reported the lowest level of work-recreation balance, and they scored lower on both the HPLP-II and SHMS V1.0 compared with those who frequently maintained a work-recreation balance. Significant association was found between work-recreation balance behaviors and healthy lifestyles (p < 0.001) after demographic adjustment. In comparison with those reporting a frequent work-recreation balance, individuals whose work-recreation balance was categorically “rare” were 1.69 times as likely to develop SHS (odds ratio (OR): 1.69, 95% confidence interval (CI): 1.49–1.92), and those with infrequent work-recreation balance (“sometimes”) were 1.71 times more likely to develop SHS (OR: 1.71, 95% CI: 1.62–1.81). These findings suggest that work-recreation balance conditions are significantly associated with, and seem to be accurate behavioral indicia of a healthy lifestyle. Poor work-recreation balance is associated with increased risk for SHS; thus, a healthier lifestyle that maintains a work-recreation balance should be promoted in order to reduce the development of SHS or disease in southern China.

The Politics of Attachment: Lines of Flight with Bowlby, Deleuze and Guattari

Research on attachment is widely regarded in sociology and feminist scholarship as politically conservative - oriented by a concern to police families, pathologize mothers and emphasize psychological at the expense of socio-economic factors. These critiques have presented attachment theory as constructing biological imperatives to naturalize contingent, social demands. We propose that a more effective critique of the politically conservative uses of attachment theory is offered by engaging with the 'attachment system' at the level of ontology. In developing this argument we draw on Deleuze and Guattari, making use of the common language of ethology which links their ideas to that of attachment theory. The attachment system can and has been reified into an image of the infant returning to their caregiver as an image of familial sufficiency. This has offered ammunition for discourses and institutions which isolate women from health, social and political resources. Yet Deleuze and Guattari can help attachment theory and research to be recognized as a powerful ally for progressive politics, for reflection on the movement of human individuation, and for arguing for the meaningful resourcing of those who care for someone else.

Variations of the social: some reflections on public health, social research and the health-society relation

The idea of a social dimension of health is widely accepted as unavoidable and relevant for public health. This article proposes a reflection around the notion of the social examining some of the manifold ways in which it might be inherited by researchers, professionals, administrative staff and material settings involved in the practices of public health care. It will be argued that this inheritance has deep consequences for efforts of care inasmuch these different versions of the social characterise, circumscribe and reframe the health-society relation, modifying the scope under which public health issues are tackled or dismissed. To ground this seemingly abstract discussion I will work considering a specific public health problem: the case of frequent attenders in public health. Drawing on two approaches from the Sociology of Health (i.e. illness-behaviour and the user-professional relation) and the field of Science and Technology Studies, I will show how these ways of framing the study of frequent attenders assume and simultaneously promote three different versions of the social. The article aims to explore how social research in these traditions participate in the achievement and promotion of specific health-society relations, in which certain notions of the social operate helping or limiting research and care efforts by creating richer or poorer possibilities for posing, examining and facing the problems of public health.