What are medical students taught about persistent physical symptoms? A scoping review of the literature.

BACKGROUND: Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management. METHODS: The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings. RESULTS: A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners' experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS. CONCLUSION: Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients.

Stigmatisation in clinical consultations for persistent physical symptoms/functional disorders: A best fit framework synthesis.

INTRODUCTION: Stigma is a social attribute that links a person to an undesirable characteristic and leads to actions that increase the social distance from that person. This includes different or discriminatory treatment. Stigma is common in healthcare, particularly in people with persistent physical symptoms (PPS) and functional disorders (FD). The aim of this study is to create a new actionable framework to aid understanding of stigmatisation in consultations about PPS/FD and to improve the consultation experiences. METHODS: This framework development used the Best Fit Framework approach to data collected for a scoping review of stigma in functional disorders. The stages included selection of an initial framework from existing conceptual models, mapping quote data from published papers to the framework and an iterative process of revision and re-mapping. The final framework was tested by re-mapping all the quote data to the framework following classification rules. RESULTS: 253 quotes were obtained from the results sections of qualitative studies from a previous scoping review. The framework comprises of prejudice, stereotypes and actions to increase social distance. Stereotype refers to the focus of stigma: this may be the condition, the patient, or their behaviour. Actions that increase social distance include: othering; denial; non-explanation; minimising, norm-breaking; and psychologising. By breaking down stigma into recognisable components, the framework provides a way to understand the difficulties that patients and clinicians face during consultations and a way to develop intervention materials. CONCLUSIONS: This new framework for stigma in clinical consultations for PPS/FDs provides a useful tool for the study of stigma in clinical consultations.

Online acceptance and commitment therapy (iACT) for adults with persistent physical symptoms - 3-month follow-up study of a randomized controlled trial.

OBJECTIVE: Persistent physical symptoms (PPS) represent a major health problem affecting daily functioning. This RCT aimed to examine whether a guided Internet-based treatment based on acceptance and commitment therapy (ACT) provided additional benefits compared to Treatment as Usual (TAU) in reducing somatic complaints and psychological distress in adults with PPS. METHODS: A total of 103 adults with PPS related to indoor environments, chronic fatigue or both conditions were assigned to receive either either a 14-week intervention (video-based case conceptualization + Internet-based ACT) combined with TAU (iACT + TAU; n = 50) or TAU alone (n = 53). Somatic symptoms, depression, anxiety, insomnia, and psychological flexibility were assessed from pre-intervention to a 3-month follow-up. Additionally, the association between changes in psychological flexibility from pre- to post-intervention and changes in symptoms from pre to 3-month follow-up was explored. Analyses were conducted using a multigroup method with full information maximum likelihood estimator. RESULTS: The results revealed a significant interaction effect, indicating reductions in somatic symptoms and symptoms of depression and anxiety with moderate to large between-group effects (d = 0.71-1.09). No significant interaction effect was observed in insomnia and measures of psychological flexibility. CONCLUSION: Internet-based ACT, when combined with Treatment as Usual, demonstrated efficacy for individuals with PPS associated with indoor environments and chronic fatigue. These findings are pertinent for primary healthcare providers, suggesting that the current treatment model could serve as a low-threshold first-line treatment option. THE CLINICAL TRIAL REGISTRATION NUMBER: NCT04532827.

Explanation for symptoms and biographical repair in a clinic for persistent physical symptoms.

Introduction: Biographical disruption describes the process by which illness impacts not just on a person's body and their participation in activities, but also on their sense of self. Biographical disruption is often followed by a process of biographical repair in which identity is reconstructed and a new normality is restored. People with persistent physical symptoms (sometimes referred to as medically unexplained symptoms) experience biographical disruption. This can be complicated by lack of explanation and the implication that if the problem is not medical, then it might be the person/psychological. We aimed to examine this tension in people attending a novel "Symptoms Clinic" for people with persistent physical symptoms. Methods: This study reports an embedded qualitative study in a UK based randomised controlled trial. Data were collected by audio recordings of consultations and semi-structured interviews with patients. We used theoretically informed thematic analysis with regular coding and discussion meetings of the analysis team. This analysis explores the role of intervention components in facilitating biographical repair. Results: The lack of acceptable explanation for persistent symptoms acted as a block to biographical repair. In the clinic, multi-layered explanations were offered and negotiated that viewed persistent symptoms as understandable entities rather than as indicators of something still hidden. These explanations allowed study participants to make sense of their symptoms and in turn opened new opportunities for self-management. The result was that participants were able to reframe their symptoms in a way that enabled them to see themselves differently. Even if symptoms had not yet improved, there was a sense of being better. This can be understood as a process of biographical repair. Conclusion: Explaining persistent physical symptoms enables biographical repair.

Multiple physical symptoms and coping strategies over the last decade - Knowledge from two Danish population-based cross-sectional studies in 2012 and 2022.

OBJECTIVE: To compare the prevalence of multiple physical symptoms, coping scores, and associations between multiple physical symptoms and coping in two population-based surveys within a 10-year interval. METHODS: A nationwide study on symptoms and healthcare-seeking, the Danish Symptom Cohort, was carried out in 2012 and repeated in 2022. For each survey, 100,000 randomly selected individuals were invited, and individuals aged 20-64 years were eligible for inclusion. Multiple physical symptoms were identified using the 25-item Bodily Distress Syndrome checklist, and coping was assessed with the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included multinomial and logistic regressions. RESULTS: A total of 35,877 were included in 2012 and 18,330 in 2022. Overall, 35.1% reported multiple physical symptoms in 2022 compared with 23.8% in 2012. The mean sum score for approach was lower in 2022 than in 2012 with a statistically significant mean difference of -1.27 (Cohen's d = -0.34), while diversion and resignation scores were significantly higher in 2022 with mean differences of 0.34 (Cohen's d = 0.11) and 0.52 (Cohen's d = 0.17), respectively. Regression analyses showed that lower approach scores and higher diversion and resignation scores were associated with an increased probability of having multiple physical symptoms in 2022, thereby confirming the results from 2012. CONCLUSION: Over the decade, symptom reporting may have increased while coping strategies may have changed towards a slightly higher use of avoidance and lower use of approach. It seems relevant to identify modifiable contributing factors in society to prevent an acceleration of symptom reporting and avoidant behavior.

Mindfulness-based intervention as a symptom management strategy in patients with end-stage renal disease: A controlled clinical trial.

AIM: The study's purpose was to examine the effect of mindfulness-based intervention (MBI) on physical and psychological symptoms in patients with end-stage renal disease (ESRD) in Jordan. METHODS: A repeated-measure randomized control study was conducted in a haemodialysis unit in Jordan between April 2023 and July 2023. Participants (N = 61) were selected using convenience sampling and then randomly assigned into experimental and control groups. The experimental group performed 30-min MBI, three times a week for 8 weeks during haemodialysis sessions. The Depression, Anxiety and Stress Scale-21 and the Patient Health Questionnaire-15 were used to measure the outcomes at baseline, after 5 weeks of the intervention and at the end of the intervention. RESULTS: Mixed-model repeated-measure ANOVAs revealed that the experimental group showed significantly lower levels of stress, depression and physical symptoms than the control group over time. Within-subject repeated-measure ANOVAs revealed that, in the experimental group, physical symptoms improve significantly over the three points of time. However, significant reductions in psychological symptoms occurred 5 weeks after initiating the intervention, but there was no further significant improvement at the end of the intervention. CONCLUSION: The study supports the integration of MBI as a symptom management strategy into nursing care plans of patients with ESRD. TRIAL REGISTRATION: Clinical trial.gov; registration ID: NCT06064708.

Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study.

Background: Holistic intensive care management involves the treatment of critically ill patients in the intensive care unit (ICU) as well as catering to family psychosocial needs helping in bettering satisfaction/perception of care. There is scarce data in the Indian intensive care setting regarding the same, especially in times of increasing end-of-life practices. Our study aimed to determine the factors impacting family perception/satisfaction with intensive care. Materials and methods: A total of 336 family bystanders of patients in ICU with more than 72 hours of stay were surveyed using family satisfaction in the ICU 24 revised (FS-ICU 24R) questionnaire. Results: Multivariable logistic regression analysis showed that the significant factors associated with the satisfaction among bystanders of ICU patients were the treatment of patient's physical symptoms like pain/breathlessness (Adjusted OR 3.73, p = 0.003), ICU staff's approach to family's need consideration (Adjusted OR 4.44, p < 0.001), concern and care towards patients' family (Adjusted OR 2.67, p = 0.023). Participation in patient care, ICU waiting room atmosphere, and emotional support are the other factors independently associated with satisfaction with ICU care. Family satisfaction was not associated with the patient's survival (p = 0.331, Chi-square test) or the length of ICU (p = 0.328, Chi-square test) and hospital stay (p = 0.865, Chi-square test). Conclusion: Treatment of a patient's physical symptoms like pain, approach to family's needs consideration, and concern/care towards the patient's family are independent factors associated with optimal satisfaction among family members of ICU patients, which even takes precedence over the survival outcomes or length of ICU stay. How to cite this article: Atri V, Bhatt MT, Chaudhuri S, Mitra A, Maddani SS, Ravindranath S. Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study. Indian J Crit Care Med 2024;28(5):483-494.

Effects of remote classes on the physical health of university students during the COVID-19 pandemic.

[Purpose] The purpose of this study is to determine how the study environment during remote classes affected the physical health of university students during the coronavirus disease 2019 pandemic. [Participants and Methods] A total of 3,359 students currently enrolled at our university participated anonymously. The survey was conducted using Google Forms, with items including "gender", "study environment during remote classes", "presence or absence of symptom", "symptoms that existed before starting remote classes", and "changes in symptoms after starting remote classes". [Results] The overall valid response rate was 49%, with a total of 688 males and 983 females providing responses. In the grouping by gender, the number of students with symptoms was significantly higher in females than in males. Similarly, the number of students with existing symptoms that were exacerbated was significantly higher in females than in males. With regards to study environment, a significantly higher proportion of students who sat on the floor during remote classes complained about exacerbated existing symptoms than those who sat on chairs. [Conclusion] The results demonstrate that remote classes during the coronavirus disease 2019 pandemic led to a higher prevalence of new physical symptoms and exacerbation of existing symptoms in females than in males, and when students sat on floors rather than on chairs.

Disentangling between-person and within-person associations of physical symptoms of depression with self-perceived health and life satisfaction: A longitudinal study in Chilean adults.

Depression is a major health problem in Chile. Evidence suggests that physical symptoms of depression (PSD) negatively impact self-perceived health and life satisfaction. The aim of this study was to determine the between-person and within-person associations of PSD with self-perceived health and life satisfaction in Chilean adults. The sample consisted of 1424 participants (64.54% female; Mage = 46.77, SD = 14.88) with data in five waves of the Social Longitudinal Study of Chile. Variables were measured through self-report questionnaires. Hypotheses were tested using multilevel analysis. At the within-person level, physical slowing, fatigue, and sleep problems were associated with poorer self-perceived health and lower life satisfaction. At the between-person level, physical slowing and fatigue were associated with poorer perceived health and lower life satisfaction. PSD are associated with self-perceived health and life satisfaction in Chilean adults longitudinally. The study highlights the importance of monitoring PSD changes in Chilean adults.

Effects of physical and psychological symptoms on cancer-related fatigue among esophageal cancer patients.

BACKGROUND: Cancer-related fatigue (CRF) is considered one of the most prevalent and distressing symptoms among cancer patients and may vary among patients with different cancer types. However, few studies have explored the influence of physical and psychological symptoms on CRF among esophageal cancer (EC) patients without esophagectomy. Therefore, this study aimed to examine the effects of physical and psychological symptoms on CRF among EC patients without esophagectomy. METHODS: In the present study, a cross-sectional study was conducted from February 2021 to March 2022 in Liaoning Province, China. Among the 112 included participants, 97 completed our investigation. The questionnaires used consisted of the Brief Fatigue Inventory (BFI), the MD Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), and demographic and clinical information. Multivariate linear regression was conducted to test the relationships between physical and psychological symptoms and CRF. RESULTS: Of the 97 EC patients, 60.8% reported CRF (BFI ≥ 4). The mean age of the participants was 64.92 years (SD = 8.67). According to the regression model, all the variables explained 74.5% of the variance in CRF. Regression analysis indicated that physical symptoms, including constipation, diarrhoea, and difficulty swallowing, contributed to CRF. On the other hand, depressive symptoms increased the level of CRF among EC patients without esophagectomy. CONCLUSIONS: Given the high prevalence of CRF among EC patients without esophagectomy, it is urgent to emphasize the importance of fatigue management interventions based on physical and psychological symptoms to alleviate CRF in EC patients.

Clinical skills development for healthcare practitioners working with patients with persistent physical symptoms (PPS) in healthcare settings: a systematic review and narrative synthesis.

BACKGROUND: The complexity and uncertainty around Persistent Physical Symptoms (PPS) make it difficult to diagnose and treat, particularly under time-constrained consultations and limited knowledge. Brief interventions that can be utilised in day-to-day practice are necessary to improve ways of managing PPS. This review aimed to establish (i) what training primary and secondary healthcare practitioners have undertaken to develop their clinical skills when working with PPS, (ii) what training techniques or theoretical models have been used within these interventions, and (iii) how effective was the training. METHOD: A systematic literature search was undertaken on eight databases to identify professional development interventions for healthcare practitioners working with PPS, were of any study design, and at a minimum were single measure studies (i.e., training outcome alone). Studies were assessed using the Mixed Methods Appraisal Tool (MMAT) and narratively synthesised. RESULTS: Despite high methodological heterogeneity across the six included studies, they all aimed to improve healthcare practitioners' communication skills through educational (theory, awareness, attitudes, assessment, treatment, and management of PPS) and experiential (role play) learning. CONCLUSIONS: The review findings demonstrate that developing healthcare practitioners' communicative behaviours led to increased confidence and self-efficacy when working with PPS, which facilitated improved consultations and improvements on some patient outcomes. Barriers to the uptake of training programmes and implementation into daily clinical practice are discussed, including the need for PPS to be formally implemented into undergraduate teaching and post-qualification continuous professional development. TRIAL REGISTRATION: This review was registered at PROSPERO [CRD42022315631] prior to the review starting.

Homelessness and Food Insecurity During Emerging Adulthood: Associations With Changes in Behavioral and Physical Health Over a Two-Year Period.

PURPOSE: For emerging adults in the United States, economic instability is a widespread problem with implications for the successful transition to adulthood. This study examines how two indicators of economic instability, homelessness and food insecurity, are associated with changes in health-related outcomes over a two-year period. METHODS: The analytic sample (N = 2,182) completed online surveys in 2019-2020 (mean age 23 years) and 2021-2022 (mean age 25 years). Regression analyses were conducted for the full sample, as well as by sexual or gender diverse (SGD) identity (17.8% of sample identified as SGD) and race/ethnicity (76.3% identified as non-White). RESULTS: At age 23, 8.2% of participants reported homelessness and 31.2% reported food insecurity. In the full sample, homelessness and food insecurity were associated with increased depression, anxiety, physical ailments, and drug problems two years later. A similar pattern emerged for those identifying as non-SGD. The only associations for SGD-identifying participants were food insecurity with increased anxiety, depression, and physical ailments. Racial/ethnic differences indicated that homelessness was associated with increased depression and anxiety among Hispanics, and physical ailments and drug consequences among Asians, but fewer drug problems among Whites. Food insecurity was associated with increased depression in all racial/ethnic groups, anxiety among Hispanics and Asians, physical ailments among Whites and Asians, and drug problems among Asians. DISCUSSION: Homelessness and food insecurity predicted worse health outcomes during the transition to adulthood, with varying results across SGD and racial/ethnic subgroups. It is important for future research to continue examining long-term effects of economic instability on health disparities during this important developmental period.

Physical symptoms and anxiety and depression in older patients with advanced cancer in China: a network analysis.

BACKGROUND: Little is understood about the association between psychosomatic symptoms and advanced cancer among older Chinese patients. METHODS: This secondary analysis was part of a multicenter cross-sectional study based on an electronic patient-reported outcome platform. Patients with advanced cancer were included between August 2019 and December 2020 in China. Participants (over 60 years) completed the MD Anderson Symptom Inventory (MDASI) and Hospital Anxiety and Depression Scale (HADS) to measure symptom burden. Network analysis was also conducted to investigate the network structure, centrality indices (strength, closeness, and betweenness) and network stability. RESULTS: A total of 1022 patients with a mean age of 66 (60-88) years were included; 727 (71.1%) were males, and 295 (28.9%) were females. A total of 64.9% of older patients with advanced cancer had one or more symptoms, and up to 80% had anxiety and depression. The generated network indicated that the physical symptoms, anxiety and depression symptom communities were well connected with each other. Based on an evaluation of the centrality indices, 'distress/feeling upset' (MDASI 5) appears to be a structurally important node in all three networks, and 'I lost interest in my own appearance' (HADS-D4) had the lowest centrality indices. The network stability was relatively high (> 0.7). CONCLUSION: The symptom burden remains high in older patients with advanced cancer in China. Psychosomatic symptoms are highly interactive and often present as comorbidities. This network can be used to provide targeted interventions to optimize symptom management in older patients with advanced cancer in China. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR1900024957), registered on 06/12/2020.

Stigmatisation in medical encounters for persistent physical symptoms/functional disorders: Scoping review and thematic synthesis.

OBJECTIVE: To conduct a scoping review of stigma in medical encounters for persistent physical symptoms and functional disorders (PPS/FD). Stigma is a social attribute that links a person to an undesirable characteristic. It has been extensively studied in relation to mental illness but less so in relation to PPS/FD. METHODS: We followed PRISMA-ScR reporting guidelines for scoping reviews. Searches for were designed using the SPIDER tool. We used descriptive and thematic analysis. RESULTS: The searches identified 68 articles, of which 32 were eligible for inclusion. 31 out of the 32 studies used a qualitative methodology. 8 studies used an explicit definition of stigma, of which 6 used the Goffman (1963) definition. Only 2 studies directly examined clinical consultations, the remainder relied on recalled accounts by patients or professionals. Descriptive analysis identified the focus of the studies included: patient-physician interaction (n = 13); health care professionals' perceptions (n = 7); experiences of illness/stigma (n = 6); broader meaning of illness (n = 3); and patients' experiences of stigma in health care consultations (n = 3). CONCLUSION: Patients experience stigmatisation in consultations for a wide range of PPS/FD. This suggests the presence of structural stigmatisation. PRACTICE IMPLICATIONS: There is a need for effective stigma reduction strategies in consultations about persistent physical symptoms.

Building coping skills to relieve distress and physical symptoms: Findings from a quality improvement project of a five-week group psychoeducational program for cancer patients.

To examine the effectiveness of Mind Over Matter (MOM), a group psychosocial intervention based on CBT, ACT, and mind-body interventions, from data collected during a quality improvement project. MOM was offered in person prior to COVID-19 and via telehealth after COVID-19 began.Distress, as measured by anxiety, depression, the severity of physical symptoms and the impact of physical symptoms on daily functioning, was measured pre- and post-MOM.The sample included 46 participants with an experience of cancer ranging in age from 31 to 75.Overall, there were significant differences in anxiety, depression, and physical symptom severity and interference pre and post MOM. The in-person intervention showed significant differences in anxiety, depression, and physical symptom interference. There were significant differences in anxiety and physical symptom severity reported in the telehealth groups.MOM may be an effective psychosocial intervention for addressing cancer-related physical and emotional challenges making it a valuable resource for institutions trying to meet needs identified by distress screenings.

Impact of painful physical symptoms on first-episode major depressive disorder in adults with subthreshold depressive symptoms: A prospective cohort study.

OBJECTIVE: To investigate the impact of baseline painful physical symptoms (PPS) on subsequent first-episode major depressive disorder (MDD) in adults with subthreshold depressive symptoms, including subgroup analyses to assess whether the associations differ in individuals with and without physical diseases. METHODS: A total of 2343 adults with subthreshold depressive symptoms were recruited at 34 primary health care centers. PPS were measured at baseline. First-episode MDD during follow-up was diagnosed by professional psychiatrists using the Mini-International Neuropsychiatric Interview. RESULTS: Baseline PPS showed independent impacts on first-episode MDD in adults with subthreshold depressive symptoms without physical diseases, but not in those with physical diseases. A non-linear association (P < 0.001) was observed between PPS burden and the risk of first-episode MDD. The HRs for first-episode MDD exhibited a rapidly increasing trend between PPS burden scores of 10-16, and maintained consistently high when scores exceeded 16. The analyses for specific PPS revealed that headache, neck pain, and heart or chest pain were independently associated with first-episode MDD in participants without physical diseases, the HRs were 1.57 (1.15-2.36), 1.53 (1.02-2.30), and 1.69 (1.14-2.50), respectively. Further network analysis demonstrated that heart or chest pain serves as a bridge symptom among the seven specific PPS and first-episode MDD in those without physical diseases. CONCLUSION: PPS burden and heart or chest pain may be significant indicators for first-episode MDD in adults with subthreshold depressive symptoms without physical diseases. Future studies should investigate whether interventions targeting PPS can prevent episode MDD in this subthreshold population.

Measuring work engagement in Thailand: development and validation testing of the Utrecht Work Engagement Scale-Thai version (UWES-TH).

This study aimed to develop and test the psychometric properties of a Thai-language version of the Utrecht Work Engagement Scale (UWES). The 17-item version of UWES was translated into Thai and a survey was conducted with 507 registered nurses at a public regional hospital in Thailand. Results showed that the alpha and omega total coefficients for the vigor, dedication, and absorption subscales were acceptable. Exploratory Structural Equation Modeling (ESEM) indicated that the three-factor model performed the best for both versions of UWES-17-TH and UWES-9-TH. Both versions correlated positively with job resources and negatively with cognitive, emotional, and physical job demands, and with emotional exhaustion and physical symptoms. They were found to have acceptable reliability and validity and can be used to study work engagement in Thai contexts. For practical reasons, UWES-9-TH might be preferred since it is shorter than the full version. Further studies should include different occupational groups and more male participants.

A Biophysical Approach to Functional Gallbladder Disorder Leads to the Hypothesis That Salmonella Plays a Relevant Role in the Etiology of This Disease: A Retrospective Observational Pilot Study.

Introduction Between 2014 and 2021, 41 patients with somatically inexplicable gastrointestinal complaints presented to the complementary and alternative medicine (CAM) practice of the author. Of these patients, 33 underwent diagnostic and therapeutic procedures in conventionally oriented practices and academic hospitals. The remaining eight participants directly reported the authors' practices. Conventional interventions did not lead to sufficient improvement in these patients. Patients and methods This study aimed to characterize the presentation and treatment results of 41 patients selected using biophysical diagnostic technology (BICOM bioresonance; Regumed GmbH, Planegg, Germany) with the working diagnosis of chronic Salmonella Cholecystitis (CSC). A retrospective observational analysis of the records of these patients was performed to provide a better understanding of their clinical picture. Results After an initial treatment period of an average of 7.5 weeks, the "end of treatment" (EOT) score could be determined. With an average of +/- 4 bioresonance sessions, 66% of the patients had a reasonable to a good reduction in complaints. This number increased after additional bioresonance therapy of the patients with comorbidities to a follow-up score (FU) of 86%. Conclusions The findings of this pilot study support the hypothesis that CSC is a well-defined clinical entity and may even coincide with the clinical picture of functional gallbladder disorder (FGD). Both can be considered as energetically informative syndromes. The study suggests that biophysical medicine may be a viable option in the diagnosis and treatment of CSC. A prospective follow-up study in an integrated setting is needed to provide more insight into these diseases.

Ambivalent identification mediates the relationship between organizational justice and stress.

The present study aims to examine the relationship between organizational justice and employee stress through the lenses of social identity theory and the ambivalent identification process. The research hypotheses assume that employees working in organizational environments with low levels of justice could experience more stress, and this relationship is also mediated by ambivalent identification. In other words, the mediating mechanism of this relation posited that low levels of organizational justice were associated with high levels of ambivalent identification, which in turn increased levels of work-related stress. Across a field study in several organizations from healthcare sectors, results confirmed that employees treated with less fairness experienced high ambivalence toward their organization, which increased their perception of stress, i.e., work-related burnout, client-related burnout, physical symptoms, and interpersonal strain at work. Furthermore, results supported only a full mediation model, in which the direct relationship between organizational justice and stress was not significant. The present results make an important contribution to the research literature on justice: the inclusion of the mediator variable, namely, ambivalent identification, drops the expected direct effect of organizational justice on stress, suggesting a call for action in adopting the social identity perspective in addition to organizational justice models, and specifically introducing the study of a detrimental form of identification, such as ambivalent identification. Limitations and practical implications of the study were discussed.