In the Journals

In the Journals: May 2013 (Part 1/2)

Hi all, here’s the first part of the journal roundup for this month. Enjoy.


Science, Technology, & Human Values

Theorizing the Bioeconomy: Biovalue, Biocapital, Bioeconomics or . . . What? (Kean Birch and David Tyfield)

In the policy discourses of the Organization for Economic Cooperation and Development (OECD) and European Commission (EC), modern biotechnology and the life sciences are represented as an emerging “bioeconomy” in which the latent value underpinning biological materials and products offers the opportunity for sustainable economic growth. This articulation of modern biotechnology and economic development is an emerging scholarly field producing numerous “bio-concepts.” Over the last decade or so, there have been a number of attempts to theorize this relationship between biotechnologies and their capitalization. This article highlights some of the underlying ambiguities in these conceptualizations, especially in the fetishization of everything “bio.” We offer an alternative view of the bioeconomy by rethinking the theoretical importance of several key economic and financial processes.


 Selective Ignorance and Agricultural Research (Kevin C. Elliott)

Scholars working in science and technology studies have recently argued that we could learn much about the nature of scientific knowledge by paying closer attention to scientific ignorance. Building on the work of Robert Proctor, this article shows how ignorance can stem from a wide range of selective research choices that incline researchers toward partial, limited understandings of complex phenomena. A recent report produced by the International Assessment of Agricultural Knowledge, Science, and Technology for Development serves as the article’s central case study. After arguing that the forms of selective ignorance illustrated in cases like this one are both socially important and difficult to address, I suggest several strategies for responding to them in a socially responsible manner.


Drinking Wastewater: Public Trust in Potable Reuse (Kerri Jean Ormerod and Christopher A. Scott)

In the coming decades, highly treated wastewater, known as reclaimed water, is slated to be a major element of municipal water supplies. In particular, planners propose supplementing drinking water with reclaimed water as a sustainable solution to the growing challenge of urban water scarcity. Public opposition is currently considered the primary barrier to implementing successful potable water reuse projects; nonetheless, public responses to reclaimed water are not well understood. Based on a survey of over 250 residents of Tucson, Arizona, this article assesses the relationship between trust in the professional institutions responsible for municipal water development and willingness to drink reclaimed water. Results demonstrate that public acceptance of potable reuse is contingent on trust in the authorities who influence design of sociotechnical systems for water supply and reuse—including water and wastewater utilities, regulators, consultants, academics, and elected local officials. Findings emphasize the highly interdependent social and political factors that inform personal decisions to support or reject potable reuse. The authors suggest that achieving greater acceptance of potable reuse will require bringing local and regional water policy in line with public values, as well as finding ways to incorporate these values into the planning process.


Values Levers: Building Ethics into Design (Katie Shilton)

As information systems transform our world, computer scientists design affordances that influence the uses and impacts of these technological objects. This article describes how the practices of design affect the social values materialized in emerging technologies, and explores how design practices can encourage ethical reflection and action. The article presents an ethnography of a laboratory that engineered software for mobile phones to track users’ locations, habits, and behaviors. This technical work raised a number of ethical challenges, particularly around questions of data use and surveillance. The ethnography suggests that particular activities within laboratories can help engineers agree on social values as important to design. It characterizes these activities as values levers: practices that open new conversations about social values and encourage consensus around those values as design criteria. Laboratory leaders and advocates can enable and strengthen these levers to encourage ethical reflection and action as an explicit part of design practice.


Making Predictions: Computing Populations (Christine Holmberg, Christine Bischof, and Susanne Bauer)

Statistics constitute the social universe of which they are gathered. The foundation necessary to develop quantified knowledge about society is the population. If quantified knowledge changes society, the question arises on how individuals become to be represented as population. The population has to be extracted from individuals in a process that we call “populationisation.” This encompasses the development of the individual into a segment of a population through the compilation of individual data into population data and its analysis. To describe the process of populationisation, we follow a statistical risk assessment tool, the German Diabetes Risk Score, from its inception in a cohort study to its entry into the public sphere of German society. The population is extracted from individuals that function as research subjects through an identification number. Preprocessed information is entered into a dynamic database that enables its rearrangement according to main aggregates. Through populationisation, a signified is enacted that can be sliced up and that is equal in all its parts. Now predictions can be computed and fed back to society as tools of moral judgment. The acting individual and “society” are—numerically and literally!—entangled in the production and enactment of risk knowledge.


Displacement of Agency: The Enactment of Patients’ Agency in and beyond Haemodialysis Practices (Wen-yuan Lin)

How might the agency of the subaltern be conceptualized within the intersection of multiple worlds? Actor-network theory’s (ANT) translation framework for understanding agency portraying this as entrepreneur and talking of a world in the making is arguably “imperialist,” “managerial,” and “monolithic.” Draws from the enactment turn of ANT and insights into the politics of representation, this article elaborates an alternative framework which focuses on displacement. By examining the case of dialysis patients, the article explores the displacing practices that follow the disruption of routines in dialysis. Patients have to go through a process of problematization, distribution, hybridization, and restabilization, in order to sustain the coexistence of their alternative practices with dialysis. Unlike entrepreneurs in the translation model who transform the world by interesting others, enduring trials, and becoming spokespersons for all, those patients who manage to displace and sustain the coexistence of multiple worlds avoid interesting, still less confronting, the hegemonic actors and claiming representation for themselves. This article suggests the displacement of agency as a generic alternative.



Constructing the moral body: Self-care among older adults with multiple chronic conditions (Laura Hurd Clarke and Erica V. Bennett)

Older adults are increasingly living with and managing multiple chronic conditions. The self-management of illness occurs in a social and political context in which the responsibility for health has shifted from the State to the individual, who is expected to be an active consumer of health care. Although there has been extensive investigation of the management of single chronic conditions, the realities of living with multiple morbidities have largely been ignored, particularly among older adults. Addressing this gap, our study entailed in-depth interviews with 35 older Canadian adults, aged 73 to 91, who had between three and 14 chronic conditions. Self-care emerged as a primary means by which our participants managed their illnesses. Specifically, all of our participants were engaged in some form of self-care in order to cope with often debilitating physical symptoms and functional losses. They also utilized self-care because they had reached the limits of available medical treatment options. Finally, our participants argued that self-care was a moral responsibility that was underscored by gendered motivations. Whereas the men tended to emphasize the importance of self-care for the achievement of masculine ideals of control and invulnerability, the women suggested that self-care allowed them to maintain feminine norms of selflessness and sensitivity to the needs of others. In this way, self-care enabled the men and women to reframe their aging, chronically ill bodies as moral, socially valued bodies. We discuss our findings in relation to the extant research and theorizing pertaining to self-care, gender, and healthism


Bodies completed: On the physical rehabilitation of lower limb amputees (Michal Hoffman)

This ethnographic study, based on empirical work carried out in an Israeli rehabilitation hospital, discusses the physical rehabilitation of lower limb amputees, during which body normalcy is re-constructed. Throughout the process, physiotherapists serve as social agents who teach pragmatic and discursive practices to manage the body as well as the prosthesis in the re-cultivation of body techniques. The findings, portraying four spheres of meaning, show that the mere use of prosthesis is insufficient since it stigmatizes the body as absent a limb. To avoid such stigmatization, the staff teach compensatory and discursive skills which enable incorporation of the prosthesis in body techniques while referring to it as a biological leg. Constructed as a ‘social organ’, the device is gradually transformed from an extension to an integral part of the body. Disability and its remedies, thereby concealed, facilitate able-bodied performance. Paradoxically, the prosthesis, though meant to benefit patients, induces pain and discomfort, a fact that challenges the acceptance of its conventionality as a medical aid for amputees. Yet, physical rehabilitation by means of prosthetics remains one of the many medical practices in Israel that ensure a disability-free society, together with the promotion of rights to accessibility and anti-discrimination regulation. The study contributes to the theoretical debate regarding the relationship between the biological and the social in disability studies. The findings indicate the need to encompass the cultural and the corporeal when exploring disability. The ethnography of disability, I suggest, should be viewed as a juncture of socio-cultural perceptions of the body, embedded in its own corporeal constraints.


Parallel vigilance: Parents’ dual focus following diagnosis of Type 1 diabetes mellitus in their young child (Selaine Niedel, Michael Traynor, Martin McKee, and Margaret Grey)

There is consensus that enabling patient self-care and expertise leads to better management of chronic illness. Clinicians are being encouraged to manage clinical encounters in ways that promote these outcomes rather than perpetuate hierarchical relationships. This article describes one part of a larger study of 55 outpatient consultations conducted within 14 months of the diagnosis of Type 1 diabetes mellitus in young children. Participants were parents and the specialist doctors, nurses, dieticians and social workers who oversee the child’s secondary care. Consultations were audio-recorded and transcribed. Our analysis draws on aspects of conversation analysis (CA) to investigate how parents’ talk enacts a growing confidence in the management of their child’s disease in the face of questioning from professionals. Analysis reveals how this talk distinguishes a duality of focus that combines the normal watchfulness exhibited by all parents as they protect their children, with an additional intense, parallel watchfulness for signs of potentially serious manifestations of diabetes. We term this phenomenon parallel vigilance and illustrate its development using five representative extracts from consultations. The concept of parallel vigilance extends the chronic illness literature and informs our understanding of a process that contributes to parents’ developing expertise and provides new and important insights into the way in which parents conceptualize and implement their evolving role in the care of their child. Moreover, parallel vigilance serves as an enabler of parental contributions to the specialist consultation.


From fatness to badness: The modern morality of obesity (Ingeborg Grønning, Graham Scambler, and Aksel Tjora)

Obesity (or being overweight) is now considered a by-product of membership of developed societies. Moreover, it is considered a growing ‘global’ health problem. This article reports on a small qualitative study of adults who fell into one or other of these categories in Norway in 2010, and who have been faced with decisions about lifestyle versus surgical remedies. This decision making is contextualized and the principal criteria examined. Embodiment, bodywork, self- and social identity, stigma, deviance and issues around the idea of personal responsibility and public health emerge as key themes. The concluding paragraphs commend incorporation of a macro- or social structural perspective to the conceptualization and investigation of obesity.


In pursuit of leanness: The management of appearance, affect and masculinities within a men’s weight loss forum (Eleanor Bennett and Brendan Gough)

In a somatic society which promotes visible, idealized forms of embodiment, men are increasingly being interpellated as image-conscious body-subjects. Some research suggests that men negotiate appearance issues in complex and varied ways, partly because image concerns are conventionally feminized. However, little research has considered how overweight men construct body projects in the context of weight loss, or how men talk to each other about weight management efforts. Since sources of information and support for overweight men are now provided online, including dedicated weight loss discussion forums, our analysis focuses on one such forum, linked to a popular male-targeted magazine. We conducted a thematic analysis of selected extracts from seven threads on the forum. Our analysis suggests a widespread focus on appearance, as well as the use of emotion categories when describing difficult bodily experiences. Invariably, however, such talk was carefully constructed and constrained by hegemonic masculinities founded on discipline, work-orientation, pragmatism and self-reliance. The findings are discussed in relation to magazine masculinities and aesthetics, as well as literature on male embodiment.


Bodies of knowledge: Nature, holism and women’s plural health practices (Carla Meurk, Alex Broom, Jon Adams, and David Sibbritt)

The proliferation of complementary and alternative medicine (CAM), and women’s high level of engagement with these practices, has presented sociology with a range of questions regarding gender, embodiment and identity work in the context of contemporary medical pluralism. The current study, drawing on 60 qualitative interviews with women from the Australian Longitudinal Study on Women’s Health (ALSWH), examines how a group of Australian women negotiate CAM and biomedicine in a range of health and illness contexts. Selected from the mid-aged cohort of this national study, here we explore their accounts of engagement with CAM and biomedicine, unpacking their logics underpinning, and rhetorical practices surrounding, their therapeutic engagement. The results provide significant insight into: the importance of ideas about nature, holism and strengthening; perceptions of the harshness and softness of medicines for women’s bodies; and, the relative importance of scientific proof vis-a-vis individual subjectivities. Ultimately, their accounts illustrate gendered and embodied strategies of strategic integration, and importantly, border crossing. We conclude that while women’s engagement with CAM and biomedicine may be indeed be gendered in character, we suggest a rethinking of gender-based resistance (to biomedicine) or gender-alignment (to CAM) arguments; the notion of women as designers would more adequately capture the landscapes of contemporary medical pluralism.



Social Theory and Health

Social inequalities in health: Notes in the margins (Gareth Williams)

This essay makes notes in the margins of the vast corpus of work now encompassed by what is termed ‘social inequalities in health’, the best of which provides important evidence about what health inequalities are, how they come about and what might be done about them. However, much of this work still does not properly connect with either wider public debates about political economy or those focussed points of attention and concern which can be found in people’s responses to the conditions in which inequality is experienced. The consequence of this is the production of policies to address health inequalities, which ignore the politics of those policies and further undermine those people already pushed to the margins by economic and political developments.


The interactions of disability and impairment (Edmund Coleman-Fountain and Janice McLaughlin)

Theoretical work on disability is going through an expansive period, built on the growing recognition of disability studies as a discipline and out of the political and analytical push to bring disability into a prominent position within accounts of the intersecting social categories that shape people’s lives. A current debate within critical disability studies is whether that study should include impairment and embodiment within its focus. This article argues it should and does so by drawing from symbolic interactionism and embodiment literatures in order to explore how differences in what bodies can do – defined as impairments – come to play a role in how people make sense of themselves through social interaction. We argue that these everyday interactions and the stories we tell within them and about them are important spaces and narratives through which impairment and disability are produced. Interactions and stories are significant both in how they are shaped by wider social norms, collective stories and institutional processes, and also how they at times can provide points of resistance and challenges to such norms, stories and institutions. Therefore, the significance of impairment and interaction is the role they play in both informing self-identity and also broader dynamics of power and inequality.


Going through the back door: Chronically ill academics’ experiences as ‘unexpected workers’ (Sharon-Dale Stone, Valorie A Crooks and Michelle Owen)

Framed around the notion that chronically ill academics are unexpected workers in an able-bodied work environment, we draw on 35 interviews with Canadian academics with multiple sclerosis (MS) to explore their experiences of seeking accommodation. This analysis draws on and extends Goffman’s (1959, 1963) theoretical concepts of ‘frontstage’ and ‘backstage’ performances and ‘stigma’ to show that getting accommodation needs met is not a straightforward process for many academics with MS. We find that seeking accommodations is highly dependent on whether or not one has disclosed having MS to others, and what institutional supports exist to assist disabled faculty members. We draw on the metaphor of ‘going through the back door’ to make sense of this finding. This analysis advances understanding of how chronically ill employees within a particular organizational culture do (or do not) get their needs accommodated, thereby adding to knowledge on chronic illness and disability accommodation in the workplace. It also sheds new light onto how the backdoor metaphor can be applied to understanding lived experiences of disability and chronic illness.


Understanding the experience of dementia: Utilising the theoretical insights of ‘status passage’ (Edward Tolhurst and Paul Kingston)

This paper critically evaluates status passage as a social theory which might enhance the research and understanding of the experience of dementia. Status passage is introduced with consideration of the theory as presented by Barney Glaser and Anselm Strauss (1971). Their theory suggests that individuals move from different stages, or statuses, throughout the life course: a long-term health condition, such as dementia, is considered such a life status. The particular value of status passage is asserted via comparison with other conceptual models of long-term illness, in particular Michael Bury’s ‘biographical disruption’. The paper proceeds to consider how the different key dimensions of Glaser and Strauss’s theory, Reversibility, Temporality, Awareness Context, Shape, Desirability, Circumstantiality and Multiple Status Passages, might apply to the empirical study of dementia. This paper concludes that status passage provides valuable theoretical resources that can enhance research across the spectrum of social scientific epistemological orientations. By encouraging theoretically guided empirical study, the utilisation of status passage could thus enhance the research of dementia, as well as contribute to a more cogent sociology of dementia.


Money, commodification and complementary health care: Theorising personalised medicine within depersonalised systems of exchange (Stuart McClean and Ronnie Moore)

Across the United Kingdom and other Western nations, complementary health care has become big business, with pressure to commercialise and technologise its goods and services. Economic liberalisation and the democratisation of health care have encouraged the increased commodification of complementary health services. This article focuses particularly on more personalised forms of complementary health care, such as folk healing, but equally highlights the importance of a whole health-care systems analysis when thinking about commodification and marketisation. We develop an exploratory synthesis of recent empirical data in the United Kingdom, in which we theorise the significance of money for complementary healthcare and folk healing. Four mutual themes and questions emerge and are presented here, with a discussion of their contribution to wider theoretical debates about money, the community, and social and health-care systems.


Re-moralising medicine: The bioethical thought collective and the regulation of the body in British medical research (David Reubi)

The way in which the scientific and medical use of the human body is problematised and governed in the United Kingdom was radically reconfigured over the last 30 years, changing from a logic of rule articulated around ‘supply’ and ‘solidarity’ to one construed around ‘ethics’. Drawing on the work of Ludwik Fleck and others, this article argues that one of the reasons for this reconfiguration was the existence and influence of a network of philosophers, doctors and lawyers who sought, from the 1960s onwards, to re-moralise medicine: the bioethical thought collective. The article first describes the collective’s membership and organisation, focusing in particular on the form of the interdisciplinary expert committee. It also describes some of the knowledge and practices that make up the community’s thought style, such as its moral concern about modern medicine and the notions of respect for persons and informed consent. The article then shows how these organisational forms, knowledge and practices that characterise the collective have shaped the government of human tissue research over the last 15 years. By highlighting the important role played by expert networks and knowledge, the article makes an original contribution to the sociology of the ethical government of biomedical science.



Philosophy, Ethics, and Humanities in Medicine

Cardiovascular medicine at face value: a qualitative pilot study on clinical axiology (Adalberto de Hoyos, Rodrigo Nava-Diosdado, Jorge Mendez, Sergio Ricco, Ana Serrano, Carmen Flores Cisneros, Carlos Macías-Ojeda, Héctor Cisneros, David Bialostozky, Nelly Altamirano-Bustamante, Myriam M Altamirano-Bustamante)

Introduction: Cardiology is characterized by its state-of-the-art biomedical technology and the predominance of Evidence-Based Medicine. This predominance makes it difficult for healthcare professionals to deal with the ethical dilemmas that emerge in this subspecialty. This paper is a first endeavor to empirically investigate the axiological foundations of the healthcare professionals in a cardiology hospital. Our pilot study selected, as the target population, cardiology personnel not only because of their difficult ethical deliberations but also because of the stringent conditions in which they have to make them. Therefore, there is an urgent need to reconsider clinical ethics and Value-Based Medicine. This study proposes a qualitative analysis of the values and the virtues of healthcare professionals in a cardiology hospital in order to establish how the former impact upon the medical and ethical decisions made by the latter.
Results: We point out the need for strengthening the roles of healthcare personnel as educators and guidance counselors in order to meet the ends of medicine, as well as the need for an ethical discernment that is compatible with our results, namely, that the ethical values developed by healthcare professionals stem from their life history as well as their professional education.
Conclusion: We establish the kind of actions, communication skills and empathy that are required to build a stronger patient-healthcare professional relationship, which at the same time improves prognosis, treatment efficiency and therapeutic adhesion.


“Advice to the medical students in my service”: the rediscovery of a golden book by Jean Hamburger, father of nephrology and of medical humanities (Piccoli Barbara)

Jean Hamburger (1909–1992) is considered the founder of the concept of medical intensive care (réanimation médicale) and the first to propose the name Nephrology for the branch of medicine dealing with kidney diseases. One of the first kidney grafts in the world (with short-term success), in 1953, and the first dialysis session in France, in 1955, were performed under his guidance. His achievements as a writer were at least comparable: Hamburger was awarded several important literary prizes, including prix Femina, prix Balzac and the Cino del Duca prize (1979), awarded, among others, to Jorge Luis Borges and Konrad Lorenz.
     Here we would like to offer a selected reading of a “golden” book, “Conseils aux étudiants en medicine de mon service” (“Advice to the Medical Students in my Service”), the first book dedicated to patient-physician relationship in Nephrology, written when dialysis and transplantation were becoming clinical options (1963). The themes include: the central role of the patient, who should be known by name, profession, life style, and not by disease; the importance of the setting of the care; the need for truth-telling and for leaving hope; the role of research not only in the progression of science, but also in the daily clinical practice.


Should trainee doctors use the developing world to gain clinical experience? The annual Varsity Medical Debate – London, Friday 20th January, 2012 (Barnabas J Gilbert, Calum Miller, Fenella Corrick, Robert A Watson)

The 2012 Varsity Medical Debate between Oxford University and Cambridge University provided a stage for representatives from these famous institutions to debate the motion “This house believes that trainee doctors should be able to use the developing world to gain clinical experience.” This article brings together many of the arguments put forward during the debate, centring around three major points of contention: the potential intrinsic wrong of ‘using’ patients in developing countries; the effects on the elective participant; and the effects on the host community. The article goes on to critically appraise overseas elective programmes, offering a number of solutions that would help optimise their effectiveness in the developing world.



International Journal of Social Psychiatry

Perceptions of boundaries and cultural influences in Qatar (Suhaila Ghuloum, Abdulbari Bener, Michael Lamport Commons, Patrice Marie Miller, F. Tuna Burgut, and Dinesh Bhugra)

Background: Boundary issues, which regularly arise in therapy, can present dilemmas for most clinicians. There has been substantial literature on boundary excursions in clinician–patient relationships, however, very little empirical research exists and is documented. As mental health researchers, we need to investigate a wide range of sensitive topics to enhance our understanding of the many issues that arise in the psychotherapeutic frame.
Aims: We set out to empirically explore perceptions of what may constitute a boundary violation among the mental health staff in the State of Qatar and their views on the subject.
Results: A total of 50 participants (24 psychiatrists, 2 doctorate level psychologists, 24 psychiatric nurses) responded with a response rate of 80%. Participants rated each possible boundary violation according to its degree of harm and professional unacceptability. Three distinct groupings of boundary violations were obtained: (1) core, consisting of the most serious violations; (2) disclosure and greeting behaviour, involving disclosure of information about the therapist and greeting behaviour; and (3) separation of therapist and client lives, involving encounters between therapists and clients outside of therapy.
Conclusions: It is important to ascertain these dilemmas so that these theoretical models can be integrated in clinical practice.


Coercion in psychiatric care: Can paternalism justify coercion? (Mi Kyung Seo, Seung Hyun Kim, and MinKyu Rhee)

Background: It has long been debated whether coercion can be justified as paternalism in the field of mental health and it is still a continuing issue of controversy today.
Aims: This study analyses whether coercive intervention in mental health can be justified by the basic assumptions of paternalists: the assumption of incompetence, the assumption of dangerousness and the assumption of impairment.
Method: This study involved 248 patients: 158 (63.7%) were diagnosed with schizophrenia and 90 (36.3%) were diagnosed with mood disorder. In this study, experiences of coercion were divided into legal status, subjective (perceived coercion) and objective experiences (experienced coercion).
Results: The assumption of incompetence was justified in all three categories of coercion whereas the assumption of dangerousness was not justified in any. The assumption of impairment was not justified in legal status and perceived coercion, but provided a partial explanation to serve as a basis for justifying experienced coercive measures.
Conclusions: It can be noted that mental health experts who support paternalism without question must reconsider their previous methods. Above all, the reason why the assumption of dangerousness was not justified in any of the categories of coercion was because coercive intervention used to prevent harm to oneself and others must be very carefully carried out.


Exposure to suicide and suicidality in Korea: Differential effects across men and women? (Min-Ah Lee, Seokho Kim, and Eun-Jung Shim)

Background: Little is known about whether exposure to suicide within close social networks is associated with the suicidality in exposed individuals, and potential gender differences regarding this association.
Aims: This study examines the effect of exposure to suicide on the suicidality in exposed individuals.
Methods: The data were drawn from the 2009 Korean General Social Survey, a nationally representative interview survey. Suicidality was measured by the suicidality module in the Mini International Neuropsychiatric Interview (MINI), with exposure to suicide being determined by asking about the experience of a failed or completed suicide attempt by a closely related person.
Results: Exposure to the suicide of someone close was significantly associated with higher suicidality in exposed individuals. While the effect of a failed attempt became non-significant after controlling for psychological factors, that of exposure to a completed act of suicide remained significant. A subsample analysis by gender indicated a significant gender difference: with control for demographic and psychological factors, exposure to a completed suicide had a significant effect on the suicidality of females only. The effect of exposure to a failed attempt became non-significant both in males and females after controlling for other factors.
Conclusions: Findings suggest the necessity of screening for prior exposure to suicide in suicide risk assessment and the need for gender-tailored suicide-prevention strategies.


Some aspects of social exclusion: Do they influence suicide mortality? (Andriy Yur’yev, Peeter Värnik, Merike Sisask, Lauri Leppik, Kaur Lumiste, and Airi Värnik)

Background: The current study is aimed to assess the relationship between the ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion and suicide mortality in Europe.
Methods: Suicide rates for 26 countries were obtained from the WHO. Data on social expenditure were obtained from the OECD database. Employment rates and GDP were obtained from the Total Economy Database. Questions about citizens’ attitudes towards different aspects of social exclusion were taken from the European Social Survey. Structural equation modelling was applied to research the theoretical structure of the variables.
Results: All variables are statistically significant in male and female models except of the relationships between ‘economic/employment’ and ‘social/welfare’ dimensions and female suicides; and the relationship between ‘employment rates’ and ‘economic/employment’ dimension. Suicide mortality rates among both males and females are influenced negatively by ‘economic/employment’ and ‘social/welfare’ dimensions. Among females, the influence of ‘social/welfare’ dimension is stronger compared to the ‘economic/employment’ dimension. The remaining influence of GDP is positive in both models.
Conclusions: Both ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion significantly influence suicide mortality among males. The influence of ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion on female suicide mortality is controversial. Social exclusion might be considered as a risk factor for suicide mortality in Europe.


Financial satisfaction and its relationship to depressive symptoms in middle-aged and older adults: Results from the FIN-D2D survey (Nina Rautio, Hannu Kautiainen, Hannu Koponen, Pekka Mäntyselkä, Markku Timonen, Leo Niskanen, Timo Saaristo, Heikki Oksa, Markku Peltonen, Hannu Puolijoki, Mauno Vanhala, and Sirkka Keinänen-Kiukaanniemi)

Background: Studies using traditional measures of socio-economic position, such as education, income and occupation, have found inequalities in depressive symptoms, but less is known about the association between financial satisfaction and depressive symptoms.
Aims: To examine the association of depressive symptoms with financial satisfaction in Finnish adults in a population-based cross-sectional FIN-D2D survey.
Methods: Four thousand, five hundred randomly selected individuals aged 45–74 years were invited to the study. Participation rate for health examinations was 64%. Complete information on depressive symptoms and financial satisfaction was available for 2,819 individuals. Financial satisfaction was asked using a questionnaire. Depressive symptoms were measured by Beck Depression Inventory (≥ 10) and/or use of antidepressants.
Results: Altogether 11.6% of individuals who were satisfied with their financial situation had depressive symptoms. Corresponding figures for individuals who were somewhat satisfied or dissatisfied were 20.6% and 42.6%, respectively. Individuals who were less satisfied with their financial situation were more likely to suffer from depressive symptoms even after adjusting for gender, age, marital status, number of chronic diseases, smoking, binge drinking, physical activity, education and household income.
Conclusions: Instead of more traditional measures of socio-economic position, financial dissatisfaction seems to be associated with depressive symptoms in Finnish adults.


Education and employment levels among Jamaican patients newly diagnosed with schizophrenia and bipolar disorder (Bertilee Burgess, Desdemona Curtis-Downes, and Roger C. Gibson)

Background: Comparisons between persons with bipolar disorder and those with schizophrenia are not well researched in the Caribbean.
Aims: To compare the educational and occupational attainments in Jamaicans diagnosed with these two disorders.
Methods: Data on diagnosis, educational level, type of employment and other basic socio-demographic variables were collected from Jamaican hospital patients who were newly diagnosed with schizophrenia or bipolar disorder. Fisher’s exact and χ2 tests, as well as binary logistic regression, were used to explore how these characteristics varied according to diagnosis. Statistical significance was taken at p < .05.
Results: Schizophrenia was associated with significantly lower educational attainment than bipolar disorder (p = .022 for educational level attained; p = .026 for completion of secondary school). The majority (87.1%) of the 93 patients included in the analysis had no specific marketable job skills. However, the proportion of persons with bipolar disorder who had such skills was three times the corresponding proportion of persons with schizophrenia.
Conclusions: The low educational achievement among persons with schizophrenia makes education a potentially important area for interventions targeted at this group. Because gross deficiencies in job skills were common to both patient groups, improvement in job skill levels is an important goal for persons with either of these disorders.


Temperament and its relation to social functioning in schizophrenia (Michelle K. Jetha, Joel O. Goldberg, and Louis A. Schmidt)

Background: We previously noted increased shyness in stable community outpatients with schizophrenia compared to healthy controls and that shyness may be a risk factor for social functioning impairment in this population (Goldberg & Schmidt, 2001).
Aims: We attempted to replicate and extend these findings by comparing the use of a brief trait measure of shyness and sociability (SS; Cheek, 1983; Cheek & Buss, 1981) with the longer Temperament and Character Inventory (TCI; Cloninger, Przybeck, Svrakic, & Wetzel, 1994) used traditionally in work to measure personality dimensions in this population.
Methods: A group of stable outpatients with schizophrenia (n = 41) and healthy controls (n = 41) matched on age and gender were compared on the SS and TCI measures. Patients were assessed on clinical symptoms using the Positive and Negative Symptom Scale (PANSS) and on social functioning measures using a Quality of Life Scale (QLS).
Results: Patients reported significantly higher shyness, retrospective inhibition and harm avoidance, and lower novelty seeking, self-directedness and cooperativeness than healthy adults, replicating previous findings. Shyness and sociability were related to conceptually linked dimensional sub-scales of the TCI and were predictive of social functioning in the patient group. Importantly, scores on these measures were unrelated to symptom profiles and explained additional variance in social functioning beyond clinical symptoms.
Conclusions: These findings suggest that individual differences in trait shyness and sociability may influence social functioning in stable outpatients with schizophrenia. The results also support the use of the brief trait measures of shyness and sociability in this population.


A recovery journey for people with personality disorder (Heather Castillo, Shulamit Ramon, and Nicola Morant)

Background: The study investigates the process of recovery for people diagnosed with personality disorder, a client group that suffers significant social exclusion known to impact on demand for health and other public services. It aims to examine efforts that attempt to reverse this social exclusion as an aspect of the recovery process.
Aim and Method: The following study aims to (1) explore what recovery means to people with personality disorder; (2) develop a conceptual model of recovery in personality disorder; and (3) evaluate the contribution of the setting (The Haven) to recovery practice. The study uses a Participatory Action Research (PAR) design. Data was collected from 66 participants by focus groups and individual interviews.
Findings: A map based on thematic analysis of data collected during the study is proposed of the recovery journey for people with this diagnosis, shown as a pyramid that represents a hierarchy of progress, from building trust through stages of recovery to social inclusion.
Conclusion: The findings offer contributions to knowledge in terms of the service design and propose a new model of recovery in personality disorder. This is defined as a journey of small steps highlighting recovery as a process rather than a goal, leading to the emergence of the new concept of transitional recovery


Influence of dependent personality status on the outcome and health service costs of health anxiety (Helen Tyrer, Peter Tyrer, and Barbara Barrett)

Objective: To assess the effect of dependent personality disturbance as an influence on the cost and clinical outcome of health anxiety.
Method: In the course of a randomized trial of treatments for patients with high health anxiety over 12 months, we also recorded dependent personality status by two methods: the Personality Assessment Schedule (an observer-rated instrument) and the self-rated Dependent Personality Questionnaire (DPQ), the latter being administered at baseline, six months and 12 months. The two main hypotheses tested were that patients with dependent personality features would have a worse outcome and attract greater health service costs.
Results: Forty-nine patients took part in the trial; all had baseline dependent personality data, 44 provided health service costs, and 38 had observer-rated personality assessments. At baseline patients with any personality disorder had higher clinical ratings for health anxiety, and dependent personality disturbance, mainly in the form of personality difficulty, was associated with a worse outcome than those without dependent personalities after correction for baseline differences. The DPQ at a score of 15 successfully identified all patients with dependent personality disorder in both ICD and DSM classifications and showed a significant but relatively modest reduction in scores of 1.5 (13%) during the course of the 12-month trial. Costs in those separated by personality status showed those with dependent personality incurred 45% more health service costs than those without these personality characteristics (p = .10). No patient with dependent personality disorder dropped out of treatment compared with 6 out of 38 (16%) of those with no dependence.
Conclusions: The DPQ is probably a reliable instrument for assessing dependent personality characteristics without the need for interview and its scores, unlike many ratings of personality, are stable over time. The findings may have been influenced by different responses to those treated in the trial with cognitive behaviour therapy compared with control treatment.


The Schedule for Evaluating Persistent Symptoms (SEPS): A new method of recording medically unexplained symptoms (Helen Tyrer, Leila Ali, Faye Cooper, Paula Seivewright, Paul Bassett, and Peter Tyrer)

Background: Medically unexplained symptoms are difficult to measure and in most cases the diagnosis is made either from independent data such as consultants’ opinions or medical outcomes, or by proxy measures such as numbers of symptoms or consultations. A valid self-rated measure would be of value in assessing this highly prevalent condition.
Aims: To describe a new scale of nine items, the Schedule for Evaluation of Persistent Symptoms (SEPS), its properties, its internal consistency, its distribution in a sample of 470 medical patients, its relationship to social functioning and health anxiety (hypochondriasis), and its construct validity by comparing its results with an independent diagnostic examination of each patient’s notes two years subsequent to assessment.
Method: A prevalence study was carried out in 405 consenting medical patients in primary care, cardiology, respiratory medicine, gastroenterology and endocrine clinics, in which the SEPS scale, the Health Anxiety Inventory (HAI) and the Social Functioning Questionnaire (SFQ) were each completed.
Results: The mean score on the SEPS scale in 470 patients was 13.4. Exploratory factor analysis revealed two main factors, one concerned focus on symptoms and the other on their attribution. Examination of all data showed a cut-off point of 14 as indicating the presence of pathological medically unexplained symptoms (MUS). Agreement between the consultants’ diagnosis and pathological MUS scores was fairly good with a score of 14 or more on the SEPS showing sensitivity of 0.65 and negative predictive accuracy of 0.90.
Conclusion: It is concluded that the SEPS scale has potential value in screening patients with suspected medically unexplained symptoms.


Quality of life and social determinants of anxiolytics and hypnotics use in women in Poland: A population-based study (Pawel Zagozdzon, Emilia Kolarzyk, and Jerzy T. Marcinkowski)

Background: The majority of studies show a substantially higher consumption of anxiolytics and antidepressants among women than among men and in the age bracket above 45 years.
Aims: To analyse association between the use of hypnotics/anxiolytics, and various characteristics of Polish women, including health-related quality of life.
Method: One thousand, five hundred and sixty (1,560) women aged 45–60 years completed a questionnaire dealing with the use of hypnotics/anxiolytics, demographic characteristics, environmental and work stress exposure, and self-reported quality of life (SF-36 form).
Results: The following variables were revealed as the predictors of hypnotic/anxiolytic use on univariate analysis: age; social pension; stress at work and environmental stress; hormone replacement therapy; headache; palpitations; mood swings or increased muscular tension; anger; duration of symptoms longer than one week; consulting a specialist; and low physical and mental health-related quality of life. The significant protective factors included: vocational and tertiary education; job satisfaction; and home as place of rest. The independent predictors of anxiolytic/hypnotic use included consulting a specialist and symptoms lasting more than one week, while job satisfaction and home as place of rest were the independent protective factors.
Conclusions: The use of hypnotic/anxiolytic medication is strongly associated with environmental and psychosocial characteristics of women between 40 and 65 years of age.



Psychosomatic Medicine

The Effect of Violent and Nonviolent Video Games on Heart Rate Variability, Sleep, and Emotions in Adolescents With Different Violent Gaming Habits (Malena Ivarsson, Martin Anderson, Torbjörn Åkerstedt, and Frank Lindblad)

Objective: To study cardiac, sleep-related, and emotional reactions to playing violent (VG) versus nonviolent video games (NVG) in adolescents with different gaming habits.
Methods: Thirty boys (aged 13–16 years, standard deviation = 0.9), half of them low-exposed (≤1 h/d) and half high-exposed (≥3 h/d) to violent games, played a VG/NVG for 2 hours during two different evenings in their homes. Heart rate (HR) and HR variability were registered from before start until next morning. A questionnaire about emotional reactions was administered after gaming sessions and a sleep diary on the following mornings.
Results: During sleep, there were significant interaction effects between group and gaming condition for HR (means [standard errors] for low-exposed: NVG 63.8 [2.2] and VG 67.7 [2.4]; for high-exposed: NVG 65.5 [1.9] and VG 62.7 [1.9]; F(1,28) = 9.22, p = .005). There was also a significant interaction for sleep quality (low-exposed: NVG 4.3 [0.2] and VG 3.7 [0.3]); high-exposed: NVG 4.4 [0.2] and VG 4.4 [0.2]; F(1,28) = 3.51, p = .036, one sided), and sadness after playing (low-exposed: NVG 1.0 [0.0] and VG 1.4 [0.2]; high-exposed: NVG 1.2 [0.1] and VG 1.1 [0.1]; (F(1,27) = 6.29, p = .009, one sided).
Conclusions: Different combinations of the extent of (low versus high) previous VG and experimental exposure to a VG or an NVG are associated with different reaction patterns—physiologically, emotionally, and sleep related. Desensitizing effects or selection bias stand out as possible explanations.


The Effect of a Primary Sexual Reward Manipulation on Cortisol Responses to Psychosocial Stress in Men (J. David Creswell, Laura E. Pacilio, Thomas F. Denson, and Maureen Satyshur)

Objective: Although previous research provides evidence for the role of rewarding activities in reducing hypothalamic-pituitary-adrenal axis responses to stress, no studies have tested whether rewards can buffer cortisol responses in humans undergoing social stressors.
Method: This study experimentally investigated whether viewing appetitive rewarding pictures reduces cortisol responses to an acute stress challenge. Fifty-four heterosexual men were randomly assigned to view either mildly erotic (reward) or neutral images (control) of mixed-sex couples before completing the Trier Social Stress Test (TSST).
Results: Participants in the reward condition had significantly lower area-under-the-curve cortisol reactivity to the TSST (mean [M] = 363.46) in comparison with participants in the control group (M = 807.06; F(1,46) = 4.84, p = .033, η2 = 0.095). Reward participants also had improved cognitive performance on the math portion of the TSST (M = 20.74) in comparison with control participants (M = 13.82; F(44) = 5.44, p = .024, η2 = 0.11). The stress-buffering effects of reward were specific to hypothalamic-pituitary-adrenal axis reactivity: the reward and control groups did not differ on psychological perceptions of anticipatory or poststress perceptions, heart rate, or blood pressure responses.
Conclusions: This research provides the first evidence linking the experience of reward with reduced stress reactivity in humans and suggests a potential novel reward pathway for coping under stress.


Association of Elevated Blood Pressure With Low Distress and Good Quality of Life: Results From the Nationwide Representative German Health Interview and Examination Survey for Children and Adolescents (Angela Berendes, Thomas Meyer, Martin Hulpke-Wette, and Christoph Herrmann-Lingen)

Objective: Quality of life is often impaired in patients with known hypertension, but it is less or not at all reduced in people unaware of their elevated blood pressure. Some studies have even shown less self-rated distress in adults with elevated blood pressure. In this substudy of the nationwide German Health Interview and Examination Survey for Children and Adolescents (KIGGS), we addressed the question whether, also in adolescents, hypertensive blood pressure is linked to levels of distress and quality of life.
Methods: Study participants aged 11 to 17 years (N = 7688) received standardized measurements of blood pressure, quality of life (using the Children’s Quality of Life Questionnaire), and distress (Strengths and Difficulties Questionnaire).
Results: Elevated blood pressure was twice as frequent as expected, with 10.7% (n = 825) above published age-, sex- and height-adjusted 95th percentiles. Hypertensive participants were more likely to be obese and to report on adverse health behaviors, but they showed better academic success than did normotensive participants. Elevated blood pressure was significantly and positively associated with higher self- and parent-rated quality of life (for both, p ≤ .006), less hyperactivity (for both, p < .005), and lower parent-rated emotional (p < .001), conduct (p = .021), and overall problems (p = .001). Multiple regression analyses confirmed these findings.
Conclusions: Our observation linking elevated blood pressure to better well-being and low distress can partly be explained by the absence of confounding physical comorbidity and the unawareness of being hypertensive. It also corresponds to earlier research suggesting a bidirectional relationship with repressed emotions leading to elevated blood pressure and, furthermore, elevated blood pressure serving as a potential stress buffer.


Sense of Coherence, Depressive Symptoms, Cardiovascular Diseases, and All-Cause Mortality (Ari Haukkala, Hanna Konttinen, Elviira Lehto, Antti Uutela, Ichiro Kawachi, and Tiina Laatikainen)

Objective: There is increasing interest in whether positive and negative psychological constructs are bipolar opposites of the same phenomenon. We examine whether a positive construct—sense of coherence (SOC)—has independent predictive power over and above depressive symptoms for cardiovascular disease (CVD) and all-cause mortality.
Methods: Participants included 3850 men and 4083 women aged 25 to 74 years who had participated in risk factor surveys conducted in 1992 or 1997. Antonovsky’s 13-item SOC scale was used to measure SOC, and had a correlation of −0.60 with the Beck Depression Inventory.
Results: During a mean follow-up time of 14.2 years, there were 670 deaths and 487 nonfatal and fatal CVD events. Higher SOC scores were associated with a lower risk of all-cause mortality (relative risk [RR] = 0.90, 95% confidence interval [CI] = 0.84–0.97 per unit), especially among men, but this association became nonsignificant after adjustment for depressive symptoms (RR = 0.99, 95% CI = 0.90–1.08). Among participants without a history of CVD, higher SOC scores were related to a lower risk for CVD (RR = 0.90, 95% CI = 0.83–0.98), but this association disappeared after adjustment for cardiovascular risk factors. Depressive symptoms remained significant predictors of CVD among women in a model including also SOC (RR = 1.24, 95% CI = 1.06–1.46).
Conclusions: SOC was related to all-cause mortality among men; the association with CVD events was modest. Measures for SOC and depressive symptoms were significantly correlated, which might result in overlap in their associations with adverse disease and mortality outcomes.


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