Clinical understanding and clinical implications of response shift

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Abstract

The purpose of this paper is to provide clinical understanding and clinical context for the concept of response shift. First, the paper describes a variety of target constructs or dimensions of health-related quality of life that are important in clinical medicine, including biological and physiological measures, symptoms, functioning, general health perceptions and overall quality of life. It is argued that insight into response shift can be gained by assessing the ways in which measures on these different dimensions change relative to each other. Second, somatization and hypochondriasis are presented as examples of clinical circumstances in which appropriate and adaptive response shifts do not occur. Third, placebo effects are defined and it is argued that response shift is one subtype of placebo effect. Finally, the role of response shift in routine clinical care and its implication for the physician–patient relationship are discussed. Although it cannot and should not replace careful attention to and appropriate treatment of abnormal biological and physiological processes, there are times when explicit attempts to produce response shifts may complement these biomedical therapies. Producing response shift probably involves understanding the psychological, social and cultural context of the illness; may be mediated by the physician–patient relationship and may facilitate coping processes in ways that improve health-related quality of life.

Section snippets

Background

The phenomenon of response shift can occur in any field where self-report data are collected. Clinicians may not consider clinical medicine a discipline characterized by self-report data, but much of the physician–patient interaction consists of talk, Roter and Hall, 1992, Lipkin et al., 1995 and the medical history is a critical component of the diagnostic process. The physician–patient relationship, physician–patient communication and interpersonal care are all increasingly the subject of

The absence of response shift: somatization and hypochondriasis

In this section, it will be argued that somatization and hypochondriasis are conditions in which `normal' or adaptive response shifts to physical symptoms do not occur. Population-based studies White et al., 1961, Verbrugge and Ascione, 1987 and studies of those presenting for medical care Backett et al., 1954, Hilkevitch, 1965, Garfield et al., 1976, Gough, 1977, Pilowsky et al., 1987, Kroenke and Mangelsdorff, 1989, Kroenke et al., 1990 show that physical symptoms are extremely common. The

Response shift and the placebo effect

This section examines the relationship between response shift and the placebo effect. There is no space to consider placebo effects in depth in this paper and interested readers are referred to more detailed recent treatments White et al., 1985, Chaput de Saintonge and Herxheimer, 1994, Gotzsche, 1994, Kleijnen et al., 1994, Laporte and Figueras, 1994, Thomas, 1994, Turner et al., 1994, Strauss and Cavanaugh, 1996.

Implications of response shift for the physician–patient relationship

According to Harrison's Principles of Internal Medicine (Isselbacher et al., 1994), the following is expected of the physician:

The practice of medicine combines both science and art. The role of science in medicine is clear. Technology based on science is the foundation for the solution to many clinical problems... Yet still in the most sophisticated application of laboratory technology or the use of the latest therapeutic modality alone does not make a good physician... [the] combination of

Recommendations for further research

This paper attempts to knit together arguments from several different intellectual traditions, and progress in further understanding this topic will depend on interdisciplinary collaboration. For example, it is interesting that recent interest in placebo effects and recent interest in describing, measuring and improving physician–patient relationships have occurred contemporaneously, but these two literatures have little overlap. This paper argues that response shift is a construct shared by

Summary

In summary, this paper tries to define response shift in terms with which clinicians are familiar and to describe it using clinical examples. A principal goal of the first part of the paper was to show that response shift is a part of routine clinical care. Somatization and hypochondriasis were then discussed in some detail and it was argued that these are clinical conditions characterized by the absence of response shift. Next, response shift was placed in a broader therapeutic and conceptual

Acknowledgements

This work was done while IBW was supported by a Picker Commonwealth Scholars Award.

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