<p>Today, health problems are likely to have a complex and multifactorial etiology, whereby psychosocial factors interact with behaviour and bodily responses. Women generally report more health problems than men. The present thesis concerns the development of women’s health from a subjective and objective perspective, as related to psychosocial living conditions and physiological stress responses. Both cross-sectional and longitudinal studies were carried out on a representative sample of women. Data analysis was based on a holistic person-oriented approach as well as a variable approach. In Study I, the women’s self-reported symptoms and diseases as well as self-rated general health status were compared to physician-rated health problems and ratings of the general health of the women, based on medical examinations. The findings showed that physicians rated twice as many women as having poor health compared to the ratings of the women themselves. Moreover, the symptom ”a sense of powerlessness” had the highest predictive power for self-rated general health. Study II investigated individual and structural stability in symptom profiles between adolescence and middle-age as related to pubertal timing. There was individual stability in symptom reporting for nearly thirty years, although the effect of pubertal timing on symptom reporting did not extend into middle-age. Study III explored the longitudinal and current influence of socioeconomic and psychosocial factors on women’s self-reported health. Contemporary factors such as job strain, low income, financial worries, and double exposure in terms of high job strain and heavy domestic responsibilities increased the risk for poor self-reported health in middle-aged women. In Study IV, the association between self-reported symptoms and physiological stress responses was investigated. Results revealed that higher levels of medically unexplained symptoms were related to higher levels of cortisol, cholesterol, and heart rate. The empirical findings are discussed in relation to existing models of stress and health, such as the demand-control model, the allostatic load model, the biopsychosocial model, and the multiple role hypothesis. It was concluded that women’s health problems could be reduced if their overall life circumstances were improved. The practical implications of this might include a redesign of the labour market giving women more influence and control over their lives, both at and away from work. </p>

Today, health problems are likely to have a complex and multifactorial etiology, whereby psychosocial factors interact with behaviour and bodily responses. Women generally report more health problems than men. The present thesis concerns the development of women’s health from a subjective and objective perspective, as related to psychosocial living conditions and physiological stress responses. Both cross-sectional and longitudinal studies were carried out on a representative sample of women. Data analysis was based on a holistic person-oriented approach as well as a variable approach. In Study I, the women’s self-reported symptoms and diseases as well as self-rated general health status were compared to physician-rated health problems and ratings of the general health of the women, based on medical examinations. The findings showed that physicians rated twice as many women as having poor health compared to the ratings of the women themselves. Moreover, the symptom ”a sense of powerlessness” had the highest predictive power for self-rated general health. Study II investigated individual and structural stability in symptom profiles between adolescence and middle-age as related to pubertal timing. There was individual stability in symptom reporting for nearly thirty years, although the effect of pubertal timing on symptom reporting did not extend into middle-age. Study III explored the longitudinal and current influence of socioeconomic and psychosocial factors on women’s self-reported health. Contemporary factors such as job strain, low income, financial worries, and double exposure in terms of high job strain and heavy domestic responsibilities increased the risk for poor self-reported health in middle-aged women. In Study IV, the association between self-reported symptoms and physiological stress responses was investigated. Results revealed that higher levels of medically unexplained symptoms were related to higher levels of cortisol, cholesterol, and heart rate. The empirical findings are discussed in relation to existing models of stress and health, such as the demand-control model, the allostatic load model, the biopsychosocial model, and the multiple role hypothesis. It was concluded that women’s health problems could be reduced if their overall life circumstances were improved. The practical implications of this might include a redesign of the labour market giving women more influence and control over their lives, both at and away from work.

This thesis focusses on the role of attentional bias for health-threat information in the production and maintenance of medically unexplained symptoms, somatoform disorders and high levels of physical symptom reporting. It is comprised of three separate papers. Paper 1 was prepared for Clinical Psychology Review as a systematic review of the evidence concerning attentional bias for health–threat information in populations presenting with somatoform/somatic symptom disorders and high levels of physical symptom reporting. From the 20 studies deemed relevant for review, it was concluded that - although limited - the evidence indicated that a relationship existed between attentional bias for health-threat information and levels of physical symptom reporting. No robust evidence was found to establish whether this relationship was a casual one. Paper 2 was prepared for Journal of Abnormal Psychology and investigated whether an exogenous cueing task could be used to reduce presumed attentional bias for health-threat information in a sample of high symptom reporting students. The results showed an unexpected attentional avoidance of health-threat information at baseline, which the study manipulation unintentionally exacerbated. No change in levels of physical symptom reporting was noted between groups (attributed to a methodological error) but a trend in relatively greater anxiety for those who received the manipulation was noted. It was concluded that avoidance may be a key factor in high symptom reporting and that this merited further research. Paper 3 provided a critical reflection of Papers 1 and 2, as well as the research process as a whole. Implications for theory and clinical practice as well as future research directions were discussed.

Background: Alongside experiencing physical symptoms with no identifiable organic cause, patients with MUS commonly experience comorbid anxiety and depression. They also have high health utilisation costs, which has implications for the health service. Interventions which target these symptoms in a cost effective way need to be developed and evaluated. Objective: To develop and evaluate a self-help mindfulness-based stress reduction (MBSR) intervention for patients with medically unexplained symptoms (MUS). Methods: A systematic review of the literature was carried out to evaluate the effectiveness of MBSR for reducing psychological distress in people with MUS. Study 1 developed and evaluated a self-help MBSR intervention in a clinical setting. Fifteen participants were recruited from eight practice, however only five completed post-intervention measures. A combination of t-tests and descriptive statistics were used to compare changes in levels of psychological distress, quality of life, symptoms and mindfulness at post-intervention. Pearson‘s correlations were used to identify relationships between improvements in mindfulness and improvements in outcomes. Study 2, exploring the reasons for the difficulties recruiting participants to Study 1, was then carried out through questionnaires to GPs. Results: Though more evidence is needed, the systematic review found MBSR to have moderate effects on psychological distress, which are largely maintained or improved at follow-up. Study 1 found symptom frequency and levels of acceptance to have improved at post-intervention. Study 2 found that the main reasons for GPs not recruiting participants was that they were busy and found it difficult to prioritise given other demands. Conclusions: Evidence to date suggests that MBSR is an effective intervention for patients with MUS. Future studies may benefit from recruiting participants from relevant organisations or using alternative methods such as database searches. No firm conclusions can be made about the self-help MBSR intervention‘s efficacy due to the study‘s limitations, however changes seen in the completer group suggest that further research would be warranted.

Medically Unexplained Symptoms (MUS) are bodily symptoms for which no organic cause has been identified, and which result in significant levels of psychological distress and functional impairment. MUS are thought to be highly prevalent in primary care settings, and have considerable costs to society. Despite evidence of overlapping psychological and physical presentations, MUS are not well understood or treated in culture that predominantly views the body through the lenses of dualism and mechanistic reductionism. An alternative 'interactive' view of the body as playing a more dynamic role is elaborated through George Kelly's (1955) Personal Construct Psychology. The author draws upon Lin & Payne's (2014) 'frozen construing' theory, and empirical literature on relationships between identity and MUS, to suggest that for people with MUS, the symptomatic body is distressing because the person is struggling to integrate its meaning with their identity. It is hypothesized that embodied processes, that may actually protect the self (and others who share a construct system with that person) from events which threaten to dramatically alter how the self is construed, are difficult to understand because of their preverbal nature. Hence symptoms, and the body itself, are dissociated from the person's more elaborated verbal self-constructions. Several hypotheses relating to this suggestion were tested using a modified form of the repertory grid technique that was designed to explore construct systems of both mind and body, for self and others. Twenty participants with MUS, recruited from the community, completed the repertory grid interviews and measures of depression, anxiety and symptom severity, which were correlated with relevant repertory grid indices to test hypotheses. Findings indicated that symptom constructs, contrary to expectations, were well integrated into participants' construct systems. The alleviation of psychological distress was significantly associated with increased perceived distance between the self in general and the self when symptoms are worst (a relationship which appeared to be independent of severity of symptoms), providing evidence of a process of dissociation that protected the current self from assimilating the undesirable characteristics that were associated with the symptom. The way in which the self when symptoms are worst is construed appeared to influence levels of distress, with more predictive power than several other indices. The study also found evidence for some participants of hypothesized relationships between desired aspects of the current self and symptoms, that would imply that symptom disappearance would actually threaten a desirable aspect of how the self is construed. Content analysis of these constructs revealed (as predicted) that such desirable aspects of self tended to relate to being responsible and sensitive to the needs of others, and were elaborated through bodily constructs in a way that suggested that they were not well integrated with the primary ways that these participants made sense of their identity. For these particular participants, discrepancies between the ideals that they had for themselves, and how they would like to be seen by others, were associated with increased depression. Several participants were identified whose constructions of self and others were dominated by constructs relating to both mental and physical strength and weakness. These participants appeared to be struggling to find coherent meaning for themselves as the result of symptoms, which were regarded as invalidating a pre-symptom construal of themselves as being 'strong'. There seemed to be a continuum of being a 'body for others' on the one hand, a previously 'strong person' on the other, and a person who is 'strong for others' in the middle. Implications for clinical practice are discussed. Although the findings of the current study are limited by a small sample size, it appears that exploring the meaning of the body in the construction of self helps to elaborate the meaning of the body and symptoms in a verbal, expressible form. This process is likely to be helpful to those who struggle to find meanings for their symptoms both in their own construct systems and in a society that objectifies the body.

This thesis examines the effectiveness of acupuncture therapy in the treatment of psychological and somatic distress in the context of medically unexplained symptoms (MUS). Also, it explores the role of psychological attachment and experiential avoidance in an effort to explain potential mechanisms of acupuncture’s effect. Existing literature demonstrates some level of effectiveness of acupuncture therapy for the treatment of depression, anxiety and somatic symptoms. However, a lack of experimental rigor in methodology means that existing results cannot be shown to be superior to a placebo and thus current treatment protocols for patients with MUS do not include a recommendation of acupuncture therapy. MUS are defined as any set of symptoms that cannot be explained by organic disease, these clusters of symptoms are theorised to be of psychological aetiology. Sufferers of MUS find themselves stuck in a perpetual loop of secondary care referrals with little or no treatment options being made available. Whilst there is some evidence that talking therapies, such as cognitive behavioural therapy, are effective, their availability, efficacy and stigma mean they are often not desired by patients who suffer with MUS. Previous research has shown that insecure attachment predicts higher instances of, psychological and somatic distress, as well as MUS. Previous work undertaken by the author of this thesis also suggests that there may be a moderating effect of attachment in acupuncture therapy outcomes. In order to investigate acupuncture’s efficacy a double-blind randomised control trial was undertaken; 63 participants were randomised to receive either five treatments of genuine acupuncture or a non-penetrating sham form of acupuncture using the Park sham acupuncture device. A rigorous procedure ensured participant and practitioner blinding to group allocation. Primary measures of psychological (GHQ) and somatic (BSI) distress were taken at pre, post and follow-up time points (8 weeks). Secondary measures included general attachment (RQ), experiential avoidance (MEAQ) and client attachment to therapist (CATS). Results showed a significant effect of acupuncture over placebo in the reduction of both psychological (GHQ) and somatic distress (BSI). This therapeutic effect was maintained at 8-week follow-up. Further results showed moderation effects of secure attachment on somatic symptoms in the treatment group but not placebo group. Experiential avoidance also moderated somatic symptom outcomes in the treatment but not placebo group. A subsequent study utilising a quasi-experimental multi-centre methodology, which used identical measures to the previous experiment, revealed the same significant reduction of both psychological and somatic distress. This study consisted of 184 participants across five clinics, each participant receiving five sessions of acupuncture. Similar results were observed regarding moderation effects of secure attachment on treatment outcomes of somatic symptoms. Results also showed differences in moderation effects between participant with a MUS diagnosis vs. those without. Findings of both studies suggest acupuncture is an effective treatment for psychological and somatic distress, as well as MUS. The differences in attachment moderation effects between treatment and placebo may indicate acupuncture’s ability to elicit endogenous opioid release in the brain. However, further neurological studies are required to confirm this hypothesis.

Objective: The perceptual mechanisms underlying the development and maintenance of excessive physical symptom reporting (i.e. 'somatisation') are poorly understood. Research with non-clinical participants suggests that high and low symptom reporters perform differently when detecting somatosensory signals and have different false alarm rates in which the presence of a signal is incorrectly reported when no signal is present. High symptom reporters often incorrectly report the presence of a signal particularly when a stimulus in a different sensory modality is presented. Previous research has shown that it may be possible to reduce false alarm rates by perceptual training using bi-modal visuo-tactile stimuli pairing. The current was designed to test this hypothesis. Methods: Seventy non-clinical participants scoring either high or low on the Patient Health Questionnaire (PHQ-15; a measure of somatisation) completed the Somatic Signal Detection Task (SSDT), a novel perceptual paradigm that purports to measure individual differences in somatosensory distortion. Prior to the SSDT, approximately two thirds of the sample completed either a 'weak' or 'strong' perceptual training protocol in which a suprathreshold tactile and visual stimuli were paired either infrequently (25%) or frequently (75%), with the intention of training participants to discriminate tactile signal from noise more effectively. The remaining participants received no perceptual training. Factors known to be strongly associated with somatisation were controlled for. Negative affectivity was controlled for using the State-Trait Anxiety Inventory Trait Version (STAI-T; Spielberger, Gorsuch & Lushene, 1970), somatosensory amplification was controlled for using the Somatosensory Amplification Scale (SSAS; Barsky, Goodson, Lane & Cleary, 1988), the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) was used to control for depression and the Health Anxiety Inventory-Short Version (SHAI; Salkovskis, Rimes, Warwick & Clark, 2002) was used to control for hypochondriacal factors with the Patient Health Questionnaire-Generalised Anxiety Disorder (PHQ-GAD-7; Spitzer, Kroenke, Williams & Löwe, 2006) being used to control for anxiety. Results: The high PHQ-15 group reported significantly more false alarms and had a significantly higher response criterion than the low PHQ-15 group in the no perceptual training conditions. The perceptual training reduced the false alarm rate for the high PHQ-15 group but did not alter response criterion. Although the findings were in the predicted direction, neither of these findings reached significance. The effect size indicated that this was due to low power. Conclusions: The findings were suggestive of the effect of perceptual training reducing false alarm rates; however, low power meant that it was impossible to draw firm conclusions. Further research with a larger sample is required.

The aim of the work presented in this thesis, was to investigate two general hypotheses derived from theories of the development and maintenance of medically unexplained symptoms (MUS) and health anxiety; that individual differences in attention to the body and somatic awareness contribute to the experience of physical symptoms and health anxiety. Three studies (an analogue pilot study, a prospective cohort study with primary care patients, and an analogue study involving a negative mood induction) were conducted to investigate the relationship between attention, somatic awareness, symptom reporting and health anxiety. In the pilot study, enhanced attentional disengagement from neutral material was associated with health anxiety and delayed disengagement from neutral material was associated with symptom reporting. In the primary care study, enhanced disengagement from neutral body-irrelevant material and delayed disengagement from threatening body-relevant material were independently associated with health care utilisation, but not symptom reporting or health anxiety. However, the longitudinal analysis revealed that attentional disengagement was neither a predictor of, or predicted by, health care utilisation. The tendency to experience distortions in somatic awareness was independently associated with symptom reporting, health anxiety and health care utilisation. Longitudinal analysis revealed that symptom reporting and health anxiety were independent predictors of somatic distortion, but that somatic distortion was not a predictor of symptom reporting or health anxiety. The results of a structural equation modeling analysis suggest that a model including both attentional disengagement and the tendency to experience distortions in somatic awareness improves understanding of symptom reporting, health anxiety and health care utilisation. In the negative mood induction study, however, neither attentional disengagement nor the tendency to experience distortions in somatic awareness were significantly associated with symptom reporting or health anxiety. The evidence presented here suggests that complex attentional processes may be associated with health seeking behaviours, possibly via a third unknown variable. This evidence, however, does not support the often-hypothesised general attentional bias for the body as a causative factor in the development of health anxiety or symptom reporting. This research has provided important evidence about attentional differences and how future research might extend the findings reported here. Furthermore, the findings regarding the tendency to experience distortions in somatic awareness provides empirical support for theories that suggest MUS may be associated with a tendency to place greater weight on top-down factors in the creation of somatic awareness (Brown, 2004; Edwards et al., 2013). However, whilst alterations in somatic awareness may be a maintenance factor for symptom reporting and health anxiety, somatic distortion may not be a causative factor in their development.

Bakgrund: Som vårdgivare möter vi ofta patienter med psykosomatiska symtom och sjukdomar, patienter med fysiska symtom som saknar tydlig organisk förklaring. Inom primärvården har cirka 30% av patienterna medicinskt oförklarliga symtom. Tidigare forskning har visat att vårdgivare känner sig osäkra och otillräckliga när de handlägger patienter med psykosomatiska symtom. Det tycks vara svårt att veta hur man ska bemöta denna patientgrupp och hjälpa dem att uppnå god hälsa. Syfte: Syftet med litteraturstudien var att beskriva hur vuxna patienter med psykosomatiska symtom upplevde mötet med och bemötandet av sin vårdgivare samt beskriva de inkluderade artiklarnas datainsamlingsmetod. Metod: En beskrivande litteraturstudie baserades på tio vetenskapliga artiklar. Artiklarna söktes fram i databaserna PubMed och Cinahl. Ansatsen på de inkluderade artiklarna var både kvalitativ och kvantitativ. Artiklarna har noggrant granskats i syfte att finna skillnader och likheter. Resultat: Patienter som fick känslomässigt stöd, förklaringar, togs på allvar och var delaktiga i beslut var de som kände mest välbefinnande och tillfredsställelse med vårdgivaren och det bemötande de fick. De patienter som möttes av oengagerade vårdgivare, blev ifrågasatta och upplevde ett motstånd, kände att de var en börda för sjukvården. De inkluderade artiklarnas datainsamlingsmetoder var intervjuer och enkäter. Slutsats: Resultatet visade att många patienter med psykosomatiska symtom sökte bekräftelse. Kommunikation var viktigt för att dessa patienter skulle känna trygghet och förtroende. Genom vidare forskning och viss förändring i omhändertagandet av dessa patienter, skulle sjuksköterskan kunna bidra med denna trygghet i större utsträckning. / Background: As healthcare providers we often meet patients with psychosomatic symptoms and diseases, patients with physical symptoms who lack clear organic explanation. In primary care, approximately 30% of patients have medically unexplained symptoms. Previous research has shown that healthcare providers feel insecure and insufficient when handling patients with psychosomatic symptoms. It seems difficult to know how to respond to this patient group and help them achieve good health. Aim: The aim of the literature study was to describe how adult patients with psychosomatic symptoms experienced the encounter with and the treatment of their healthcare providers, and to describe the data collection methods of the included articles. Method: A descriptive literature study based on ten scientific articles. The articles were searched in the PubMed and Cinahl databases. The included articles were designed both qualitative and quantitative. The articles have been carefully reviewed in order to find differences and similarities. Result: Patients who received emotional support, explanations, were taken seriously and participated in decisions were those who felt most well-being and satisfaction with the care and the response they received. Patients who were met by uncommitted healthcare providers, and were questioned and experienced a resistance from their providers, were those who felt that they were a burden on healthcare. Data collection methods in the included articles were interviews and questionnaires. Conclusion: The result showed that many patients with psychosomatic symptoms sought confirmation. Communication was important for these patients to feel safe and confident. Through further research and some change in the treatment of these patients, the nurse could contribute to this safety to a greater extent.

CFS/ME (Chronic Fatigue Syndrome/Myalgic Encephalomyelitis) is a distressing and potentially debilitating condition. It can also be understood as a contested condition, surrounded by controversy about its nature, causes and treatment. Previous research indicates that those affected experience this climate of contestation as a troubling and discrediting assault, not only on the nature of their condition, but also on their identities. However, little attention has been paid to the voices of young people living with CFS/ME. This thesis extends a relatively small literature in new directions, focusing a constructionist, discursive narrative lens on the accounts of ten young people (aged 13-18) living with a diagnosis of CFS/ME. Narratives constructed during repeated interviews over a year, and drawing on multimodal materials collected by participants over that period, were analysed for their content, structure and performance, with reference to the local and broader contexts of their production. This analysis demonstrates that teenagers construct rich, multi-layered narratives with the potential to enhance understanding of their situation and broader features of the social world. As they speak of the onset of illness, attempts to live with enduring, unpredictable symptoms and their psychosocial consequences, and (for some) the possibility of 'moving on' from the worst of illness, this analysis throws new light on how young people's narratives can be understood as simultaneously constructing the condition ('M.E.') and the identities of those involved ('me' and others), in ways that engage with, reflect and resist prevailing discourses. It is argued that the discursive contexts of CFS/ME and adolescence raise particular challenges for young people as they try to construct credible narratives that convey the full extent of their difficulties, while resisting stigmatising identities (eg, as 'complaining', 'lazy' or otherwise 'not normal'). This analysis highlights implications for them, their families and those who work professionally with them; and for the ongoing social construction of CFS/ME in young people.