Finnish doctors and the realisation of patient autonomy in the context of end of life decision making.

Patient autonomy is a fundamental principle in end of life decision making. However, its realisation may take a variety of forms. Discourse analysis was conducted in a qualitative interview study of 19 physicians. The physicians made use of three different discourses, each of which contained a specific understanding of patient autonomy and a physician's proper activities in the context of end of life decision making.

Vicissitudes of pain and suffering: chronic pain and liminality.

This article looks at how the Finnish experience of chronic pain is shaped by socio-cultural practices. Along with the ambiguity that is necessarily present in all chronic illnesses, the invisibility of chronic pain blurs biomedical categorization and confuses diagnostics. This results in a double delegitimation--that of suffering a chronic illness and that of suffering chronic pain--which, obviously, has a serious effect on one's experience of pain as well as on one's self-identity. I draw upon data collected from my interviews (conducted in a pain clinic in Finland) with patients who, for years, have suffered from chronic pain. People who are in pain feel that they have lost something precious, and, as a result, their subjectivity--their sense of who they are--becomes altered. This finding is in keeping with what we have learned from previous studies of chronicity. However, unlike Sue Estroff's (1993) and Jean Jackson's (1994) findings with regard to chronic illness (i.e., that it may be specifically located on a continuum of subjectness), my findings with regard to chronic pain indicate that it is ambiguous, that it involves a continuous back-and-forth movement along a continuum of subjectness. This movement involves reconciling one's self with, as well as distancing one's self from, pain; and it reflects the biomedical construction of chronic pain. In contrast to those narrative studies of chronic illness that represent illness as a "biographical disruption," my interviews with Finnish patients indicate that those living with chronic pain experience continual disruptions--chronic pain being one among many.

Chronic pain as a posture towards the world.

This article discusses what chronic pain is "about", what the intentional object is of pain, and what is the intentional relation like? My approach is based on Maurice Merleau-Ponty's phenomenology, with an aim is to understand a two-way relationship: how the sufferers bestow meaning on chronic pain, and how pain, on the other hand, signifies peoples' life. In contrast to biomedical and cognitive-behavioral theories, chronic pain is not only meaningful, but as an intentional emotion as well; it does not simply "happen" in the nervous system. I analyzed meanings assigned to pain through the narratives of three patients with chronic pain. Pain is described as creating a discontinuity in the patient's Lebenswelt at the narrative level. When attempting to find meaning to their pain, patients point both to everyday life and biomedical referents. The structure of bestowing meaning is, metaphorically, like a necklace with everyday world and biomedical interpretations strung like beads, one after the other. The intentional object of pain, on the contrary, is constituted of the patients' world in its wholeness. My results don't confirm Drew Leder's idea of disrupted intentionality, but underline directness as the basic relation of human experience also in case of pain and disease. Pain in itself is an e-movere, an intense passionate movement, an intentional relation with and a bodily posture taken towards the world.

Pregnancy and diabetes--a hermeneutic phenomenological study of women's experiences.

The aim of this article is to describe women's experiences of being pregnant and having insulin-dependent diabetes mellitus (IDDM), particularly regarding what the crucial elements of the experience are during pregnancy. A qualitative method with a hermeneutic phenomenological approach was used. The subjects were 14 pregnant women with IDDM, of whom eight were primiparous and six multiparous. They were interviewed during pregnancy concerning their experience of 'being controlled by blood glucose levels for the child's sake'. The child makes demands, with consequences which are divided into two main themes: objectification, including loss of control and an awareness of having an unwell 'risky body'; and exaggerated responsibility, including constant worry, constant pressure and constant self-blame. The results present a challenge to every midwife, physician or other health professional involved in the care of pregnant women with diabetes. They have an important role in mediating understanding of how risks to such women during pregnancy and childbirth can be minimized by normalizing the blood glucose level. At the same time, they should point out the fact that most women with IDDM today have healthy babies. This could reduce negative feelings. The women should also be supported and encouraged in the normal transition to motherhood.

Clinical characteristics of migraine concordant monozygotic twin pairs.

OBJECTIVES: The aim of the study was to search for clinical differences between migraine with and without aura. MATERIALS AND METHODS: From a population-based Finnish Twin Cohort we studied 51 migraine concordant monozygotic twin pairs. RESULTS: There were 20 pairs concordant for migraine with aura, 6 pairs concordant for migraine without aura and 12 "mixed" pairs. In the remaining 13 pairs the aura of at least 1 twin could not be classified. All 20 migraine with aura pairs were concordant for visual aura and 19 for moderate or severe headache while all 6 pairs with migraine without aura were concordant for headache duration of 4 to 24 h, moderate or severe headache and nausea. The 12 "mixed" pairs had more often unilateral and pulsating headache compared to both the migraine with or without aura pairs. Overall individual migraine with aura twins had more photophobia (P = 0.032) and the migraine without aura twins more nausea (P = 0.025). CONCLUSIONS: The difference between migraine with and without aura is not explained entirely by genetical factors: 12 genetically identical twin pairs were discordant for the aura. The headache phase in migraine with and without aura is very similar, but not identical. Probably there are several and different liability loci for the migraine aura and the migraine headache. The distribution of these several loci along with acquired factors will decide whether the phenotype is migraine with or without aura.

Clinical characteristics of migraine in a population-based twin sample: similarities and differences between migraine with and without aura.

OBJECTIVE: To look into clinical differences between migraine with and without aura in a population-based sample of migraineurs. BACKGROUND: Migraine presents in two major forms, migraine with and migraine without aura. With the exception of the aura phase, the clinical characteristics of these entities are very similar. Despite this, however, the recent epidemiological data underline differences between migraine with and without aura. We tried to examine whether other features besides the aura differ between these two major forms of migraine. METHODS: We studied 321 twins suffering from migraine with aura and 166 twins with migraine without aura from the population-based Finnish Twin Cohort. Migraine was diagnosed according to the criteria of the International Headache Society (IHS). Analysis was based on the combination of a mailed questionnaire and a telephone interview by a neurologist. Special attention was paid to differences between migraine with and without aura. RESULTS: Some qualities of headaches differed between IHS defined migraine with and without aura. Unilateral headache (Chi-squared p = 0.039) and photophobia (Chi-squared p = 0.010) were more typical for migraine with aura, while nausea was more typical for migraine without aura (Chi-squared p = 0.002). Duration of headache in migraine without aura was also longer than in migraine with aura (Mann-Whitney U-test 0.007). CONCLUSIONS: There are clinical differences between IHS defined migraine with and without aura; even the headache phase between the two entities differs. It is worthwhile distinguishing between them when looking for the elusive genes for these more common forms of migraine.

Changes in neuropsychological symptoms and moods among tanker drivers exposed to gasoline during a work week.

The purpose of this study was to investigate changes in the neuropsychological symptoms and moods among tanker drivers during a work week and the associations of the changes with exposure to gasoline (including 10% methyl-tert-butyl ether). The target group for the study consisted of 101 road tanker drivers from three Finnish oil companies in various parts of Finland. The control group consisted of 100 milk delivery drivers from two milk companies from the same localities. Interviews were conducted before the work week and at the end of the same work week. Standardized symptom questionnaires were used to elicit responses to questions about symptoms and moods. In the questionnaires tanker drivers scored significantly higher in the fatigue scale at the end of the work week than before the work week. Our findings show that tanker drivers with long exposure to gasoline during the work week developed significantly higher changes in fatigue scores than drivers with short exposure. During the exposure situations, 20% of tanker drivers reported acute symptoms (headache, dizziness, nausea, dyspnoea, irritation of saliva excretion) at the end of work week voluntarily. These symptoms have been connected, with MTBE (methyl-tert-butyl ether) exposure, among others. Exposure to MTBE during the work week can be reason for acute symptoms among the tanker drivers in this study.

Neuropsychological symptoms among tanker drivers exposed to gasoline.

The purpose of this study was to investigate the occurrence of neuropsychological symptoms over periods of one week and one month among tanker drivers as related to exposure to gasoline (methyl-tert-buthyl ether 10%). Milk delivery drivers acted as controls. In addition to exposure to gasoline, age, chronic diseases, perceived health, working time, work history in the occupation of driver and alcohol consumption were scrutinized for their associations with the symptoms. The target group for the study consisted of 101 road tanker drivers from three Finnish oil companies all around Finland. The control group was 100 milk delivery drivers from two milk companies from the same localities in Finland as the tanker drivers. Standardized symptom interviews were conducted for all drivers. The differences in the occurrences of neuropsychological symptoms between tanker drivers and controls were not statistically significant. The age of the drivers, chronic diseases and perceived health were connected to the occurrence of symptoms among drivers. The results of this study do not exclude the possibility that vulnerable groups exhibit an increased sensitivity to gasoline.

Recent interpersonal conflict at work and psychiatric morbidity: a prospective study of 15,530 employees aged 24-64.

Relationships between psychiatric morbidity and interpersonal conflict at work among 15,530 Finnish employees aged 24 to 64 years were studied in a prospective follow-up: 4 years for all psychiatric hospitalizations, 5 years for suicide, and 6 years for long-term medication due to chronic psychosis. The association between interpersonal conflict at work and physician-diagnosed psychiatric morbidity was significant (RR 2.18, 95% CI 1.34-3.54) when results were adjusted for general health status, social class, and mental instability/stress. Results remained significant in additional models adjusted for neuroticism, marital status, conflict with spouse, and high alcohol consumption. The results were similar for both sexes.

Interpersonal conflict as a predictor of work disability: a follow-up study of 15,348 Finnish employees.

This 6-year follow-up study investigates the impact of interpersonal conflict at work on work disability among 8,021 male and 7,327 female employees aged 24 to 65 years at baseline. Marital status, marital conflict, monotonous work, hectic work pace, hostility, neuroticism, life dissatisfaction, and experienced stress of daily activities were included in survival analyses, which were adjusted for age, social status, and general health status. Interpersonal conflict at work predicted work disability only among women (RR 1.56, CL 1.01-2.39). This risk was confined to women who reported simultaneous marital conflicts (RR 2.54, CL 1.03-6.22). When included in further analyses, life dissatisfaction was a significant risk factor among both genders, but monotonous work, neuroticism, and experienced stress of daily activities were risk factors only among men. These data suggest that interpersonal conflict could be a determinant of work disability, and this indicates the importance of gender and marital factors.

Migraine and concomitant symptoms among 8167 adult twin pairs.

We studied the inheritance of migraine and concomitant symptoms among 2690 monozygotic (1524 female and 1166 male) pairs and 5497 dizygotic (2951 female and 2546 male) twin pairs. Our material consists of a population-based questionnaire study among Finnish twins in 1981. The definition of migraine is based on a questionnaire method. Concordance was assessed using probandwise concordance rates and tetrachoric correlations for monozygotic (MZ) and dizygotic (DZ) twin pairs. For estimating the contribution of genetic factors to the susceptibility of migraine, a polygenic multifactorial model was used. Structural equation models were applied for estimating variance components and to compare different genetic models. Nearly one-half (40% to 50%) of the liability to migraine is attributable to genetic factors. In all structural analyses, the model with both additive genetic and unshared environmental component had the best goodness-of-fit value. The genetic component varied between 34% to 51% in different migraine types. There were no remarkable differences between sexes except in the effects due to dominance, where the proportion was 26% for men and 14% for women. Concomitant symptoms among subjects within pairs concordant for headache had genetic effects varying from 56% (subjects with unilaterality) and 56% (subjects with visual symptoms) to 45% (persons with nausea and vomiting). The two threshold model of headache points to the continuum model of headache, and the thresholds represent different levels of severity of the pain. Our results emphasize a multifactorial and higher than previously reported genetic pattern in the etiology of migraine. Also unshared environmental factors play an important role.

The use of tranquilizers, hypnotics and analgesics among 18,592 Finnish adults: associations with recent interpersonal conflicts at work or with a spouse.

The use of tranquilizers, hypnotics, and analgesics was assessed by a postal questionnaire in a nationwide sample of 18,592 adults aged from 24 to 65 years: 14,800 employees, 2105 housewives and 687 unemployed persons. The use of tranquilizers was most frequent among unemployed persons whereas housewives did not use the studied medicines more than the employed women. In the multivariate analyses (adjusted for age, social class and neuroticism) unmarried status was associated with the use of tranquilizers and hypnotics among both genders. Reported recent interpersonal conflicts both at work and with a spouse were associated with the use of tranquilizers among men, whereas among women significant associations were found only for conflicts with a spouse. These results indicate that domestic factors are more likely to predict women's tranquilizer use.

A population-based survey of headache and migraine in 22,809 adults.

A population-based epidemiological study of the prevalence of headache in a sample of 24,682 adults was carried out in Finland. Enquiries were made concerning the frequency of headache, migraine and characteristics of headache attacks in a questionnaire survey in 1981. Headache was classified as migraine, and headache without migrainous features. Possible somatic causes of headache were excluded by record-linkage with three nation-wide medical registries. The prevalence of both headache types depended on age and gender. Among women the overall prevalence of migraine was 10.1% with a maximum of 11.5% in the 40-49 age group. The prevalence rate among men was 2.5% and the female/male gender ratio was 4.0. Women with migraine had an average of 52.5 headache occasions during a year and men with migraine 61 headache occasions per year. At the individual level, headache without migrainous features was least invalidating. There were only 16.5 headache occasions a year among women and 11.5 among men. However, from a population perspective headache without migrainous features accounted for 46.5% of all headache occasions among women and for 60.8% among men. Thus, from the public health view-point, studies of "non-clinical" headache, e.g. headache without migrainous features should be emphasized.

Interpersonal conflicts at work and psychosocial characteristics of employees.

Associations of psychosocial factors with interpersonal conflicts at work were studied in a sample drawn from the Finnish population using a mailed questionnaire. The sample consisted of 14,578 employees aged 24-64 years. The frequency of interpersonal conflicts at work was equal among both sexes. Our results suggest that occupational factors such as hectically paced work, monotonous work and white collar status are associated with interpersonal conflicts at work; and more conflicts are found in the younger age-groups. In the multivariate analyses, dissatisfaction with life, daily stress, neuroticism and hostility were found to be the significant risk factors for interpersonal conflicts at work for both sexes, whereas a higher educational level was a considerable risk factor only for men, and low self-assurance only for women. Among men the combination of hectically paced and monotonous work was also found to be a significant risk factor. The results indicate complexity of the concept of human relationships at work, and the importance of both occupational factors and psychological characteristics.