When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting.

The United States is experiencing one of its largest migratory waves, so health providers are caring for many patients who do not speak English. Bilingual nurses who have not been trained as medical interpreters frequently translate for these patients. To examine the accuracy of medical interpretations provided by nurses untrained in medical interpreting, we conducted a qualitative, cross-sectional study at a multi-ethnic, university-affiliated primary care clinic in southern California. Medical encounters of 21 Spanish-speaking patients who required a nurse-interpreter to communicate with their physicians were videorecorded. Encounters were transcribed by blinded research assistants. Transcriptions were translated and analyzed for types of interpretive errors and processes that promoted the occurrence of errors. In successful interpretations where misunderstandings did not develop, nurse-interpreters translated the patient's comments as completely as could be remembered and allowed the physician to extract the clinically-relevant information. In such cases, the physician periodically summarized his/her perception of the problem for back-translation and verification or correction by the patient. On the other hand, approximately one-half of the encounters had serious miscommunication problems that affected either the physician's understanding of the symptoms or the credibility of the patient's concerns. Interpretations that contained errors that led to misunderstandings occurred in the presence of one or more of the following processes: (1) physicians resisted reconceptualizing the problem when contradictory information was mentioned; (2) nurses provided information congruent with clinical expectations but not congruent with patients' comments; (3) nurses slanted the interpretations, reflecting unfavorably on patients and undermining patients' credibility; and (4) patients explained the symptoms using a cultural metaphor that was not compatible with Western clinical nosology. We conclude that errors occur frequently in interpretations provided by untrained nurse-interpreters during cross-language encounters, so complaints of many non-English-speaking patients may be misunderstood by their physicians.

The role of attachment in responses to victims of life crises.

Attachment effects on affect, cognitions, and behavior during an interaction with a confederate who purportedly had cancer and whose attachment orientation had been manipulated in a prior context were examined among 241 participants. Results supported theoretically derived predictions: Participant anxious attachment predicted anxiety, participant avoidant attachment predicted supportiveness, and participant avoidant attachment interacted with confederate avoidant attachment to predict rejection. Results suggest (a) the importance of attachment in predicting interpersonal responses in a nonromantic stressful context, (b) that anxious attachment is an important predictor of anxiety in a situation with implicit support demands, (c) that avoidant attachment is a potentially important predictor of the likelihood of supportive responses to victims, and (d) that attachment orientation can be successfully manipulated in experimental studies of attachment.

Somatization: a debilitating syndrome in primary care.

Somatization is a significant problem for clinical medicine. Unlike somatization disorder, which is relatively rare, abridged somatization, a less severe form of somatization, is prevalent in primary care clinics. The authors examined the clinical status and functioning of patients diagnosed with a depression or anxiety disorder comorbid with abridged somatization and compared them with patients diagnosed with a depression or anxiety disorder alone. The authors examined severity of physical functioning and psychopathology in relation to diagnostic status. Patients diagnosed with both abridged somatization and a depression or anxiety disorder were more physically impaired and more anxious than those diagnosed with a depression or anxiety disorder alone. The results suggest that abridged somatization frequently coexists with depression and anxiety and thus complicates the presentation of these disorders.

Traumatic life events in primary care patients: a study in an ethnically diverse sample.

OBJECTIVE: To examine among immigrants and others seeking primary care: (1) the prevalence, types, and predictors of traumatic life events; and (2) the relations among traumatic life events, psychiatric disorders, and utilization of primary care services. DESIGN: Survey with structured diagnostic interview. SETTING: Community-based, university-affiliated primary care clinic in southern California. PARTICIPANTS: Fourteen hundred fifty-six adult patients representing 4 ethnic groups (Mexican immigrants, Central American immigrants, US-born Latinos of Mexican descent, and US-born non-Latino whites). DEPENDENT MEASURES: Rates of traumatic events measured with the Posttraumatic Stress Disorder section of the Diagnostic Interview Schedule; psychiatric disorders identified by the Composite International Diagnostic Interview using Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria; physical functioning (Short Form Health Survey); and the number of medical clinic visits during a 6-month period. RESULTS: Nearly 10% of patients had experienced a traumatic event in the previous year, and 57% had experienced at least 1 during their lifetimes. The most common forms of trauma were interpersonal violence occurring outside the family (21%), acute losses or accidents (17%), witnessing death or violence (13%), and domestic violence (12%). When compared with the US-born non-Latino whites, Mexican immigrants were half as likely, and Central American immigrants were 76% more likely, to report having experienced a traumatic event. Married individuals were significantly less likely to report traumas. Traumatic experiences, female gender, and non-Latino ethnicity were associated with the presence of a psychiatric disorder. One-year and lifetime psychiatric disorders were associated with poorer physical functioning and an increased number of clinic visits during a 6-month period. CONCLUSIONS: Traumatic life events are common and associated with psychiatric disorders other than posttraumatic stress disorder in an ethnically diverse sample of primary care patients. Psychiatric disorders, in turn, are strongly associated with poor physical functioning and higher rates of primary care utilization. Screening for traumatic experiences should accompany assessments of psychiatric disorders to ensure adequate treatment of patients seeking primary care services.

Patient centeredness in medical encounters requiring an interpreter.

PURPOSE: Patient-centered interviewing is associated with greater patient satisfaction and better medical outcomes than traditional encounters, but actively seeking patients' views of their illnesses and encouraging patients to express expectations, thoughts, and feelings is difficult in encounters that require an interpreter. We sought to examine physicians' use of the patient-centered approach with patients who required the assistance of an interpreter. SUBJECTS AND METHODS: A cross-sectional sample of patients was videorecorded during visits with physicians at a multi-ethnic, university-affiliated, primary care clinic. Nineteen medical encounters of Spanish-speaking patients who required an interpreter and 19 matched English-speaking encounters were coded for frequency that patients mentioned symptoms, feelings, expectations, and thoughts (collectively called "offers"). Physicians' responses were coded as ignoring, closed, open, or facilitative of further discussion. RESULTS: English-speaking patients made a mean (+/- SD) of 20 +/- 11 offers, compared with 7 +/- 4 for Spanish-speaking patients (P = 0.001). Spanish-speaking patients also were less likely to receive facilitation from their physicians and were more likely to have their comments ignored (P <0.005). English-speaking patients usually received an answer or acknowledgment to their questions even if the physicians did not encourage further discussion on the topic. CONCLUSION: Spanish-speaking patients are at a double disadvantage in encounters with English-speaking physicians: these patients make fewer comments, and the ones they do make are more likely to be ignored. The communication difficulties may result in lower adherence rates and poorer medical outcomes among Spanish-speaking patients.

Searching for meaning in loss: are clinical assumptions correct.

Three assumptions guiding research and clinical intervention strategies for people coping with sudden, traumatic loss are that (a) people confronting such losses inevitably search for meaning, (b) over time most are able to find meaning and put the issue aside, and (c) finding meaning is critical for adjustment or healing. We review existing empirical research that addresses these assumptions and present evidence from a study of 124 parents coping with the death of their infant and a study of 93 adults coping with the loss of their spouse or child to a motor vehicle accident. Results of these studies indicate that (a) a significant subset of individuals do not search for meaning and yet appear relatively well-adjusted to their loss; (b) less than half of the respondents in each of these samples report finding any meaning in their loss, even more than a year after the event; and (c) those who find meaning, although better adjusted than those who search but are unable to find meaning, do not put the issue of meaning aside and move on. Rather, they continue to pursue the issue of meaning as fervently as those who search but do not find meaning. Implications for both research and clinical intervention are discussed.

A hierarchical classes analysis (HICLAS) of primary care patients with medically unexplained somatic symptoms.

This study used a clustering model, Hierarchical Classes Analysis (HICLAS), to examine patient groupings in a multiethnic sample of 1456 patients using primary care services at a university-affiliated community clinic in southern California. Somatic symptoms, psychiatric diagnoses and disability were studied using a survey instrument that included portions of the Composite International Diagnostic Interview (CIDI), the Diagnostic Interview Schedule (DIS) and the RAND-MOS Short Form Health Survey's (SF-36) 'physical functioning' dimension. HICLAS identified 11 clusters of patients with distinct patterns of medically unexplained somatic symptoms. These patient clusters varied with respect to psychiatric diagnoses and symptoms, gender, immigration status and disability. Results of this study suggest that the type of presenting symptom(s) and their various combinations may have diagnostic and prognostic value in primary care settings. These new findings may lead to further refinement of current diagnostic constructs for somatizing syndromes.

Abridged somatization: a study in primary care.

OBJECTIVE: We examined the prevalence, correlates, and predictive value of an abbreviated somatization index, based on specific symptom thresholds, in primary care patients using services at a university-affiliated clinic. METHOD: We interviewed 1456 patients with a survey instrument that included the Composite International Diagnostic Interview (CIDI) to elicit symptoms and diagnoses of several psychiatric disorders as well as demographic information and a measure of disability. Statistical analyses examined the relationship of abridged somatization with physical functioning and various demographic and diagnostic factors. RESULTS: About one fifth of this primary care sample met the abridged somatization criteria. "Somatizers," defined according to these criteria, had significantly higher levels of psychiatric comorbidity and disability than "nonsomatizers". Analyses taking into account the number and type of organ/body systems represented by the unexplained symptoms showed that this dimension adds specificity to the prediction of outcomes. Thus, regardless of the total number of medically unexplained symptoms, abridged somatization with unexplained symptoms attributable to four or more organ/body systems showed the strongest association with disability and psychopathology. CONCLUSIONS: Abridged Somatization is a frequent syndrome in primary care that is strongly associated with psychopathology and physical disability. Our research also yielded a new series of abridged somatization subtypes (eg, "discrete" vs. "comorbid" and "simple" vs. "polymorphous") that may effectively separate among various psychopathologies, and may become useful tools for future research with somatizing patients.

DSM-IV hypochondriasis in primary care.

The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.

Getting "stuck" in the past: temporal orientation and coping with trauma.

The relations between temporal orientation and long-term psychological distress were studied cross-sectionally and longitudinally in 3 samples of traumatized individuals: adult victims of childhood incest, Vietnam War veterans, and residents of 2 southern California communities devastated by fire. Results indicated that a past temporal orientation--focusing attention on prior life experiences--was associated with elevated levels of distress long after the trauma had passed, even when controlling for the degree of rumination reported. Temporal disintegration at the time of the trauma--whereby the present moment becomes isolated from the continuity of past and future time--was associated with a high degree of past temporal orientation over time and subsequent distress. Temporal disintegration was highest among individuals who had experienced the most severe loss, had previously experienced chronic trauma, and had had their identities threatened by their traumatic experience.

Somatisation disorder in primary care.

BACKGROUND: Somatisation is a common and frustrating clinical problem in primary care. METHOD: Using structural diagnoses and functional measures, we examined the prevalence and associated features of somatisation disorder defined by three current nosologies and an abridged construct in subjects using primary care services. RESULTS: Somatisation disorder, diagnosed according to the standard criteria, was found to have a very low prevalence (range 0.06-0.5%), while more than one-fifth of the sample (22%) met the criteria for the abridged diagnosis. There was poor agreement between succeeding versions of the DSM system for identifying cases of somatisation disorder, each system ending up with rather disparate sets of individuals as well as variable levels of psychopathology and disability. CONCLUSIONS: According to these data, standard somatisation disorder diagnoses add little to the prediction of disability/psychopathology beyond the contributions of an abridged construct of somatisation.

Narratives of Somatizing and Non somatizing Patients in a Primary Care Setting.

Somatizing patients, who comprise approximately 20 percent of the primary care population, often present physicians with recurrent but confusing combinations of symptoms without organic explanations. Illness narratives presented during initial medical encounters with primary care physicians were examined qualitatively to determine if the narrative structure, chronological development of symptoms and temporal frame differed between somatizing and non-somatizing patients. Following a structured interview to identify somatization tendency and co-morbidities of depression and post-traumatic stress disorder, 116 patients' encounters with primary care physicians were video-recorded and transcribed. Somatizers demonstrated a narrative structure that was similar to that of non-somatizing patients, but they used a thematic rather than a chronological development of symptoms and they did not convey a clear time frame. Somatizing patients with a co-morbid psychological condition focused on concrete physical sensations, were unable to provide contextual history or chronological organization, and did not develop a temporal frame. The narratives of somatizing and non-somatizing patients differed sufficiently to warrant further research for use as a clinical aid in the diagnosis of somatization.

Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers.

The study examined how social constraints on discussion of a traumatic experience can interfere with cognitive processing of and recovery from loss. Bereaved mothers were interviewed at 3 weeks (T1), 3 months (T2), and 18 months (T3) after their infants' death. Intrusive thoughts at T1, conceptualized as a marker of cognitive processing, were negatively associated with talking about infant's death at T2 and T3 among socially constrained mothers. The reverse associations were found among unconstrained mothers. Controlling for initial level of distress, there was a positive relation between T1 intrusive thoughts and depressive symptoms over time among socially constrained mothers. However, higher levels of T1 intrusive thoughts were associated with a decrease in T3 depressive symptoms among mothers with unconstrained social relationships.

Religion's role in adjustment to a negative life event: coping with the loss of a child.

Parents (N = 124) who had lost an infant to sudden infant death syndrome were interviewed 3 weeks and 18 months postloss. Two components of religion (religious participation and religious importance) were assessed, and their relations with 3 coping-process variables (perceived social support, cognitive processing of the loss, and finding meaning in the death) were examined. Greater religious participation was related to increased perception of social support and greater meaning found in the loss. Importance of religion was positively related to cognitive processing and finding meaning in the death. Furthermore, through these coping-process variables, religious participation and importance were indirectly related to greater well-being and less distress among parents 18 months after their infants' deaths. Results suggest that further study of the social and cognitive aspects of religion would be profitable.

Reconsidering the attribution-adjustment relation following a major negative event: coping with the loss of a child.

Field studies have not yet conclusively established how attributions affect adjustment to unanticipated traumatic events. This may be due, in part, to the adoption of several untested assumptions in most prior research. It has usually been assumed that attributional issues are important to people who experience a traumatic event, that such concern is adaptive, and that specific attributions (e.g., self-blame) influence subsequent adjustment. These assumptions were tested with longitudinal data collected over 18 months from 124 parents whose child died of Sudden Infant Death Syndrome. By 3 weeks postloss, 45% of parents were not concerned with attributional issues. These parents were less distressed and less likely to blame themselves or others for the death. Longitudinal analyses did not support the assumption that attributions influence subsequent adjustment. Rather, attributions to onself or others appear to be symptomatic of distress.

Characteristics of participants in a large group awareness training.

A study was conducted to assess the psychosocial characteristics of individuals who become involved in large group awareness training (LGAT) programs. Prospective participants in The Forum, which has been classified as an LGAT, were compared with nonparticipating peers and with available normative samples on measures of well-being, negative life events, social support, and philosophical orientation. Results revealed that prospective participants were significantly more distressed than peer and normative samples of community residents and had a higher level of impact of recent negative life events compared with peer (but not normative) samples. Prospective participants also held preparticipation values more similar to those espoused by the LGAT than peer or normative samples, and the three groups failed to be distinguished by their levels of social support. The implications of the findings are considered for understanding participation in LGATs and other self-change promoting activities.

The myths of coping with loss.

Drawing from theory and clinical lore, we consider how individuals are assumed to cope following irrevocable loss. Several assumptions are reviewed reflecting beliefs concerning the grieving process. Specifically, we examine the expectation that depression is inevitable following loss; that distress is necessary, and failure to experience it is indicative of pathology; that it is necessary to "work through" or process a loss; and that recovery and resolution are to be expected following loss. Although limited research has examined these assumptions systematically, available empirical work fails to support and in some cases contradicts them. Implications of our analysis for theoretical development and research are explored. Finally, we maintain that mistaken assumptions held about the process of coping with loss fail to acknowledge the variability that exists in response to loss, and may lead others to respond to those who have endured loss in ways that are unhelpful.