EMPIRICAL STUDIES doi: 10.1111/scs.

12289

Understanding persons with psychological distress in primary

health care

Tina Arvidsdotter RN, PhD (Research Project Manager)1,2, Bertil Marklund GP, MD (Professor)2,3, Sven

n PhD (R&D Director)2, Charles Taft PhD (Associate Professor)1,4 and Inger Ekman RN, PhD (Professor)1,4
Kyle
1
Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Primary Health Care
Research Development and Education Centre, V€anersborg, Sweden, 3Institute of Medicine, Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden and 4Centre for Person Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden

Scand J Caring Sci; 2016; 30; 687–694
Understanding persons with psychological distress in
primary health care
The purpose of this study was to gain more knowledge
and a deeper understanding of experiences of persons
living with psychological distress who seek help in pri-
mary care. Psychological distress is a state of emotional
suffering associated with stressors and demands that are
difficult to cope with in daily life. The lack of effective
care for and difficulty in identifying psychological dis-
tress is frustrating for patients and health professionals
alike. The aim was therefore to gain more knowledge
about the experience of living with psychological dis-
tress. Twelve persons (nine women and three men)
aged 23–51 years were interviewed. Analyses were
based on a phenomenological hermeneutic method and
indicated that psychological distress may be seen as an
imbalance (incongruence) between the self and the
ideal self, which slowly breaks down a person’s
self-esteem. This imbalance was described in three
dimensions: Struggling to cope with everyday life, Feeling
inferior to others and Losing one’s grip on life. It seems to
be associated with a gradual depletion of existential
capacities and lead to dissatisfaction, suffering, poor
self-esteem and lack of control. As psychological distress
may be a forerunner to mental, physical and emotional
exhaustion, there is a need to initiate preventive or
early interventions to avoid mental, physical and emo-
tional chaos in such patients. Patients’ with psychologi-
cal distress need to be involved in a person-centred
salutogenic dialogue with health professionals to
become aware of and strengthen their own capacities
to regain health and well-being.
Keywords: anxiety, depression, lived experience,
phenomenological hermeneutic method, primary health
care, psychological distress.
Submitted 1 March 2015, Accepted 13 August 2015

related to depression, anxiety and burnout (15, 16).

Background
Psychological distress (PD) is a common mental health
problem in the community (1–4). PD is a state of emo-
tional suffering typically characterised by symptoms of
depression and anxiety (4–6). These symptoms often
coexist (7) and co-occur with common somatic com-
plaints (8–11) and a wide range of chronic conditions
(12), as well as with medically unexplained syndromes
(13, 14). Risk factors include stress-related and sociode-
mographic factors and inadequate inner and external
resources (4). Stress in particular has been found to be
Correspondence to:
Tina Arvidsdotter, Institute of Health and Care Sciences, The
Sahlgrenska Academy, University of Gothenburg and Primary
Health Care Research Development and Education Centre,
Edsgatan 1c, 462 35, V€anersborg, Sweden
E-mail: tina.arvidsdotter@vgregion.se
Work-related factors, such as high demands, poor support
and lack of control, contribute to PD (17).
Although considerable research has explored the symp-
tomology and epidemiology of PD, few studies have
described patients’ actual experiences of living with this
condition. A review of the literature on PD (6) identified
five defining characteristics of patients living with PD:
perceived inability to cope, changes in emotional status,
discomfort, communication of discomfort and harm.
Based on analyses of interviews with 179 Quebecians,
Mass
e (18) found that experiences of living with PD can
be expressed in six general idioms: demoralisation and
pessimism towards the future, anguish and stress, self-
depreciation, social withdrawal and isolation, somatisa-
tion and withdrawal into oneself.
Primary care provides the first line of care for mental
health problems, and most persons who seek treatment for
PD are treated solely at this level (8, 19–21). General

© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of 687
Caring Science.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
688 T. Arvidsdotter et al.

practitioners estimate that about 25% of their patients
have mental health problems, including PD (22). Unfortu-
nately, PD often goes undetected in primary care since it
may be masked by physical complaints and poly-
symptomatology (21, 23, 24). Lengthy and ineffective
treatments often lead to frustration both for the health
professional (25–27) and for the patient (25, 28). Poor
detection and lack of effective treatments for PD suggest
the need for more understanding of PD from the patient
perspective in order to better meet each patient’s needs for
care. The aim of the present study was therefore to gain
more knowledge about the experience of living with PD.
women and three men) aged 23–51 years presenting
with complaints of PD, such as worry, mild-to-moder-
ate anxiety or depression, sleep disturbances, fatigue,
headache or somatic pain, a mix of different psycho-
logical and somatic symptoms and different diagnoses
(Table 1).
Prospective participants were recruited by healthcare
professionals at the primary care centres. They were sub-
sequently contacted by phone by the first author (TA)
who informed them about the study, in line with ethical
research principles (31). All 12 contacted patients agreed
to participate in the study.

Method Data collection

Design and setting
In-depth, semi-structured, individual interviews were
conducted to gain an understanding of patients’ experi-
ences of living with PD. The interviews were analysed by
means of a phenomenological hermeneutic method (29)
inspired by Ricoeur (30) to elucidate the essential mean-
ing of the described experiences. The interviews were
conducted at four primary healthcare centres (two pri-
vate and two public) located in two towns in western
Sweden, with populations of 15 000 and 40 000. The
study was approved by the Regional Ethical Review
Board, Gothenburg, Sweden (No. 120-10).
Participants
The sampling was purposive to attain lived experi-
ences of PD. Interviewees comprised 12 persons (nine
Individual interviews were conducted in 2010–2011 by
the first author (TA) and lasted between 22 and 61 min-
utes (median 38 minutes). The participants were asked to
narrate their experiences of living with PD. The opening
question was as follows: Can you please tell me what it
is like to live with your condition? Follow-up probes
included, How did you think or feel? and Can you tell
me more? The location, time and length of interview
were decided by the participants.
Data analysis
A phenomenological hermeneutic approach as
described by Lindseth & Norberg (29) and inspired by
Paul Ricoeur’s theory of interpretation (30) was
employed. It consists of three steps that are performed
back and forth in a hermeneutical spiral approach.
The first step, naive reading, involves becoming familiar

Table 1 Description of participants

Gender Status Children Working Sick leave Unemployed Main diagnosis (ICD-10)

Female M Yes 100% F 43.8 Other reactions to severe stress

Female M Yes 100% F 32 – Depressive episode
Female S Yes 100% F 51 Nonorganic insomnia
Female S No 100% K 58.9 Irritable bowel syndrome
Female M Yes 100% F-33 Recurrent depressive disorder
F 43.9 Reaction to severe stress, unspecified
Female S No 100% F 43.9 Reaction to severe stress, unspecified
F-32 Depressive episode
Man M No 100% F 41 – Panic disorder
Man M No 100% F 32 – Depressive episode
Female S No 100% F 43.8 – Other reactions to severe stress
M 791 – Myalgia
Female M Yes 100% F 41 Panic disorder
G 44.2 Tension-type headache
Female M Yes 100% R 10.4 Other and unspecified abdominal pain
F 43.8 Other reactions to severe stress
Man M Yes 100% G 44.2 Tension-type headache

Status; M – married/cohabiting and S – single.

© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
Caring Science.

with the text in order to grasp its meaning as a
whole. In the second step, structural analyses, the text
is divided into explanatory meaning units, which are
then grouped into subthemes and themes. Finally, in
the third step, interpreted whole or comprehensive under-
standing, the text is read again and the themes and
subthemes are reflected on in relation to the research
question and the context of the study. The analysis
and interpretation was discussed until the authors
reached consensus.
Results
Naive reading
The interviewees described their everyday life as being
dominated by feelings of tiredness, anxiety and worry
about being unable to live up to demands and expec-
tations of others. They explained that they concealed
their feelings and thoughts ‘behind a mask’ as a way
of coping with these demands and tried to give the
impression that they were ‘on top of things’. This had
a negative effect on their self-image. They also iso-
lated themselves from others, which in turn led to
feelings of loneliness and exclusion. The experience of
losing control was described as being in a state of
exhaustion. These feelings had developed over several
years, sometimes since childhood and adolescence or
from negative job-related events. The interviewees
experienced great difficulties in managing their every-
day lives and turned to primary care for symptoms
such as worry, anxiety, depressed mood, sleep distur-
bance or pain.
Structural analysis
The structural analysis process resulted in three themes:
Struggling to cope with everyday life, Feeling inferior to others
and Losing one’s grip on life (Table 2).
The subthemes illuminate various aspects of the themes
and are illustrated by quotations from the interviews.
Table 2 Themes and subthemes that were emerged from the
structural analysis
Struggling to cope Feeling inferior Losing one’s
Themes with everyday life to others grip on life
Subthemes Feeling hunted Self- Losing zest for
depreciation life
Warning signals from Social isolation Disorientation
the body
Fluctuating feelings Shutting out
feelings
© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
Caring Science.
Experiences of Psychological Distress 689
Struggling to cope with everyday life
The theme Struggling to cope with everyday life comprised
three subthemes: Feeling hunted, Warning signals from the
body and Fluctuating feelings (Table 2).
Feeling hunted. The interviewees explained that they
were constantly worried and fearful about being unable
to meet demands at home or at the workplace and they
tried to alleviate those feelings. Things that had previ-
ously caused no concern, such as a family member or
themselves being involved in an accident or afflicted by a
disease now worried them.
My professional judgment somehow got confused
when I got too close. . . I know better. . . than to put
myself into another family0 s situation. . . but
sometimes reason fails. . . and then, yes. . . then it
happens. . . it’s the fear I suppose. . .of losing them
[family members]. . .I want to get rid of that feel-
ing. . .the feeling of being hunted. . . A lot of it started
earlier. . . of course it affects me, my life. . .otherwise
I wouldn’t be sitting here with you’. (man, 42) ‘I
feel worried all the time. . . that something will
happen to me or the children.. or to my partner. . .
(women, 31)
Warning signals from the body. The interviewees experi-
enced various symptoms in conjunction with their
distress. They explained that they felt tense and unable
to relax. Sleep was disturbed by restlessness and despite
extreme fatigue it was impossible to fall asleep. They
also had headaches, stomach problems, dizziness, pres-
sure over the chest and pain. The symptoms increased
in intensity when the emotional state deteriorated and
sometimes developed into extreme anxiety, oftentimes
with a fear of dying. Health professionals were contacted
to obtain help or to explain what was happening to the
body.
‘. . . sometimes it feels as if you are coming down
with fever, you get extremely hot and have palpita-
tions and it feels like you. . . are going to die but you
don’t know why. . . difficult to breathe and it feels as
if you. . . cannot control your body. Like losing the
ability to move. It’s difficult to explain’ (woman, 23)
‘I’ve always fought against my body. . . and sort of
tried convincing myself that I’ll keep control . . .
Good girl, who can manage everything. . .’ (woman,
31) ‘I often get headaches. . . and it feels like all the
muscles in my head are aching and pressing
together. . . I get palpitations. . . I feel like my chest is
jumping. . . I feel tired. . .’ (man, 42)
Fluctuating feelings. Emotional life was described as erra-
tic and unbalanced and could fluctuate several times a
day between feeling happy and crying, anger, hopelessness
690 T. Arvidsdotter et al.
and despair. Their tolerance level decreased and they
became easily frustrated and angry with family
members.
‘I’m almost falling apart inside. . .the children are too
much for me. . .I get very angry and irritated, it feels
as if something is ticking away inside. . .you feel like
you’ll explode’. (woman, 31)’. . . I yell at them. . . the
frustration I get from my boss. . . I transfer to my
children. . .’ (woman, 43) ‘I can feel. . . sad and apa-
thetic and quite detached. . .. . . then the next day. . . I
can laugh and feel quite happy’. (woman, 31)
Feeling inferior to others
The theme Feeling inferior to others comprised two
subthemes: Self-depreciation and Social isolation (Table 2).
Self-depreciation. Self-depreciation was described as
subordinating or suppressing one’s own needs, wishes,
opinions and thoughts, and instead trying to live up to
others expectations and demands of how one should be
and act. They explained that they assumed unrealistic
responsibilities for duties at home and at work and
depreciated themselves when they inevitably failed.
Oftentimes this resulted in either assuming even more
responsibility or avoiding responsibilities out of fear of
new failure.
‘. . . The frustration involved in not daring to stand
up. . . for myself, it’s something I’m reminded of
every day. . . it’s the same there. . . never dared to
stand up for my older sister. . . throughout my child-
hood’ (woman, 26) ‘It’s something I don’t tell my
employer. . . you feel you have to keep up appear-
ances all the time. . .’ (woman, 49) ‘I have put
others’ wishes above my own all the time. . . It is
hard to accept that I am human and can actually do
wrong. . . yes, (crying), it is difficult’ (woman, 47)
‘It’s an inner compulsion. . . to please others. . .’
(woman, 43)
Social isolation. Social isolation was described as feelings
of loneliness and exclusion. The interviewees explained
that they isolated themselves from family, friends and
colleagues and felt they were a burden to them. They
also felt that they could not turn to them for support and
understanding and withdrew more and more into
themselves.
‘. . . Yes, it’s really hard. . . that all the time. . . I have
the feeling that. . . others (colleagues) dislike me and
see me as a burden. . .’ (man, 45) ‘I feel like an
strange bird. . . I. . . don0 t really belong. . . to what is
going on around me (crying) . . . and that is
an (draws a deep breath). . . that’s an awkward
feeling. . .’ (woman, 47)
© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
Losing one’s grip on life
The theme Losing one’s grip on life comprised three
subthemes: Losing zest for life, Disorientation and Shutting
out feelings (Table 2).
Losing zest for life. Losing zest was described as a sense of
being drained of energy, motivation and interest. They
described their fatigue as all-encompassing, affecting all
levels of mental, bodily and emotional life. Lacking the
‘base’ that had previously provided security, life was
experienced as meaningless and chaotic. Sometimes
thoughts about not having sufficient strength to go on
living also emerged.
‘. . . I felt empty somehow. . . very empty. . . that I
wasn’t capable of anything, I felt sort of worthless. . .
many mornings when I was driving to work I had a
sort of lump in my stomach, a big stone. . . I know
that I had thoughts like. . . when driving on the
motorway . . . that it would be best if I had an acci-
dent. . . and this doesn’t work anymore. . . I need to
get in contact with a doctor. . . I can’t bare this. . .’
(woman, 43) ‘The whole thing started when I could
not get out of bed. And I didn’t want to, I didn’t
want any more. . .’ (woman, 31)
Disorientation. The interviewees explained that they
oftentimes felt confused and forgetful. They felt that
they had difficulties in maintaining or following the
thread of a conversation or in finding words. They also
complained about difficulties in concentrating when
reading a book or watching TV. The feeling of dis-
orientation brought with it fears that they were seriously
ill.
‘. . . the loss of memory was considerable. . . I had
great difficulty remembering ordinary things . . . it
was a complete blackout. I couldn’t control
anything’ (woman, 43)’. . . I forget words, can0 t
remember names of things. . . It is a scary feeling. . .
O, God. . . is something wrong in my head?. . . Do I
have Alzheimer’s?’ (woman, 47)
Shutting out feelings. Emotional life was described as
dulled and numbed. Emotions became colder, less empa-
thetic and the inclination to give and receive love
disappeared.
. . . I’m aware of empathy. . . but I have become
much colder. . . so I feel a bit more manly. . . perhaps
it’s to protect myself so to speak when I get tired
and worn out, then I push everything away from
me, I don’t want love. . . I can’t handle it . . . I
thought that I would find my way back to the
children, but I’m afraid I didn’t and that was fright-
ening. (woman, 49)
Caring Science.

Interpreted whole
The comprehensive interpretation of the interview texts
yielded three themes of PD: Struggling to cope with everyday
life, Feeling inferior to others and Losing one’s grip on life.
Struggling to cope with everyday life concerned efforts to
manage difficult or excessive demands in order to gain
control over everyday life. The distress associated with
the inability to cope with demands was manifested in
various symptoms and was coupled with fluctuating
emotions, which together contributed to a sense that
something was seriously wrong in the patient’s life and
to feelings of inadequacy. Carl Rogers (32) described this
feeling when he stated that we all have a conception of
what we are like (the self) and another of how we would
like to be (the ideal self). Rogers used the term incongru-
ence to denote a state when these two images are discor-
dant, which in turn leads to dissatisfaction with
ourselves. The theme Feeling inferior to others was charac-
terised by self-doubt about social and professional skills
and abilities and self-worth and a concomitant difficulty
or reticence to set boundaries and to stand up for and
express one’s own thoughts, opinions, needs and wishes.
Conflicts that arose were difficult to resolve. This in turn
led to feelings of self-reproach and decreased self-esteem.
Self-depreciation concerned the perception of lacking
support and understanding and can result in a feeling of
being a burden to colleagues and family members. Such
individuals try to maintain their sense of self-esteem by
hiding behind a mask or projecting their unresolved feel-
ings on to other people. It is burdensome and difficult to
live up to one’s ideal self-image. The interviewees
explained that their self-esteem was undermined and
that they felt of less value than others. Rogers (32) claims
that people reconstruct their dissatisfaction using false
masks, facades or roles in order to protect themselves by
means of a ‘false self’. The mask is a vehicle by which
the individual attempts to think, feel and act on the basis
of other people’s demands and expectations. Searching
for one’s true self (the self) can be both arduous and
painful. Rogers refers to S€ oren Kierkegaard who stressed
that ‘the most common despair is to be in despair at not
choosing, or willing, to be oneself, but that the deepest
form of despair is to choose, to be another than oneself’.
On the other hand, the will to be that self which
one truly is, is indeed the opposite of despair, and this
choice is the deepest responsibility of human beings
(p. 110) (32). Our interpretation of the meaning of living
with PD can be seen as a lack of balance between the
individual’s demands on the ideal self and the real self,
leading to poor self-esteem. The three dimensions of the
course of PD, struggling to cope with everyday life, feel-
ing inferior to others and losing one’s grip on life, all
indicate a struggle towards regaining oneself. The theme
© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
Caring Science.
Experiences of Psychological Distress 691
Losing one’s grip on life was interpreted as a feeling that
energy and resources are depleted. The zest for life is lost
and the feeling of meaninglessness and emptiness devel-
ops into an existential crisis. Disorientation includes the
fear of becoming seriously ill and fears of no longer
having the strength to go on living may emerge. Emotions
are shut off to be able to go on living.
Discussion
Our analyses yielded three dimensions of the experience
of living with PD: struggling with everyday life, feeling
inferior to others and losing one’s grip on life. In ‘Strug-
gling to cope with everyday life’, there seems to be
enough energy to actively meet the demands of daily life.
This dimension reflects a striving to present oneself as a
strong and productive person, which is essential for one’s
self-esteem (ideal self) and is a central driving force to
balance constant daily demands (15). Previous studies, in
concordance with our findings, have indicated that one
of the initial signs of stressors and demands seems to be
manifested by symptoms (15, 16, 33, 34). They may be
interpreted as signals from the body that something is
wrong through, for example, muscular pain or nervous-
ness, anxiety or fluctuating emotions (18). People with
PD have been found to ignore such signals (15) claiming
they have no time to be ill (16) or to recognise them but
not ‘listen’ to them (33). This was also confirmed in our
findings. Stijn and Paul (35) describe the dissonance
between the self and ideal self metaphorically as ‘a crack
[that] appears in the mirror’.
In the dimension ‘Feeling inferior to others’, energy
seems to be decreased, and self-esteem seems to be
broken down gradually. There is a fear of not being ‘good
enough’ in both private life and at the workplace
(15, 16, 33). This can be interpreted as an existential
suffering, that is a suffering of the self. Mass
e (18) identi-
fied it as ‘withdrawal into oneself’, which is ‘the core of
distress’. The person has difficulty controlling life and is
unable to handle adverse events. He/she undervalues
and judges him/herself and withdraws from social
contexts and becomes socially isolated. This lack of bal-
ance between the self and the ideal self is also confirmed
by Gustafsson et al. (33). Incongruence is a state in
which there is an imbalance between the person one
wants to be and what one is capable of becoming. It is
useless to live up to an ideal, an image that is discon-
nected from reality and leads to emotional suffering. The
ideal self then loses its function and ‘the mirror falls
down’ (35).
The dimension ‘Losing one’s grip on life’ describes
experiences of fatigue and that emptiness, meaningless
and loss of control are spreading. These dimensions can
be interpreted as preceding exhaustion and seem to be a
692 T. Arvidsdotter et al.

gradual process which slowly breaks down the person’s
self-esteem (4, 15, 33, 35). The dimension is charac-
terised by a sense that one cannot cope with daily
demands (4–6, 36, 37), that the self and body are split
(16), that one’s limits have been exceeded (34) and that
one is living ‘in-between’, isolated from oneself and from
others (15). There is a deep conviction that the future
will only get worse, interest in life is lost, apathy sets in
(18) and it all ends up in an existential breakdown (6,
15, 16, 33). The feelings of stress and experiences of
failure and shame mean that a tiny drop can cause the
barrel to overflow with the risk of triggering a downward
spiral of mental, physical and emotional suffering. The
dimension can be seen as a forerunner to mental, physi-
cal and emotional exhaustion, as previous studies have
shown that loss of control ends up in an existential chaos
(15, 16, 33, 34). The work is no longer chosen as a
medium in which ideals can be projected, the person
‘withdrawl from the mirror’ (35).
Our interpretation of the three dimensions can be seen
as three different dimensions within PD. The dimensions
seem to be characterised by varying resources or capaci-
ties to cope with PD. Our findings are in line with Mass
e
(18) who showed that the dimensions are not universal
or stable, rather fluctuate from one stage of an episode to
another, from person to person and from context to con-
text. PD may be seen as a manifestation of excessive
external requirements on the whole person, regardless of
diagnoses. It would be valuable for the health profession-
als to understand the characteristics of different
dimensions of PD and therefore find ways to approach
the patient. Active listening by the health professional to
the patient’s illness narrative is a way to help the patient
find his/her own resources and ability to cope with the
condition and, thereby, strengthen the life process and
the development of self-awareness towards free will and
healing.
Conclusions and implications
Our interpretation of living with PD may serve to guide
health professionals in their care for patients with PD.
We believe that PD may be a precursor to exhaustion,
and timely and appropriate care may help to avoid its
development. Patients and professionals need to be aware
of these signs since they may predispose mental, physical
and emotional chaos. The challenge is to recognise and
understand the patient’s existential resources and hinders
and to see the person from a holistic, salutogenic and
person-centred perspective (36, 38), in order to help
patients find a balance between what they can manage
and their limits for recovery (39–41). When an imbal-
ance exists between the ideal self and the real self (32),
the challenge is to help patients find a balance between
what is realistic and possible in order to live a good life.
The study results may be hypothesis generating for future
intervention research where such individualised
treatments can be tested and evaluated to know when
and how the patient should be treated to avoid mental,
physical and emotional exhaustion.
Acknowledgements
We wish to thank all participants, the leaders and the
primary care staff who made this study possible. We
gratefully acknowledge the financial support from the
Ekhagastiftelsen and Research and Development Center
Fyrbodal V€anersborg.
Author contributions
Tina Arvidsdotter, Inger Ekman and Charles Taft planned
the study and examined the na€ıve understanding. Tina
Arvidsdotter was responsible for the data collection and
guided the co-authors in the analysis process. All the
authors (Tina Arvidsdotter, Bertil Marklund, Sven Kyl
en,
Charles Taft and Inger Ekman) took part in the analysis
process from the structural analysis to the comprehen-
sive understanding. All authors were involved in the
preparation of the manuscript.
Ethical approval
Regional Ethical Review Board, Gothenburg, Sweden
(No. 120-10).
Funding
The funding sources were not involved in the design,
analysis or writing process. The authors declare that they
have no competing interests.

References 2 Marchand A, Drapeau A, Beaulieu- Mental Health Problems and use of

1 World Health Organization. The
World Health Report 2001: Mental
Health: New Understanding, New Hope.
2001, World Health Organization,
Geneva.
Prevost D. Psychological distress in Health Services in Ireland. HRB Research
Canada: the role of employment and Series 5, 2008, Dublin: Health
reasons of non-employment. Int J Soc Research Board.
Psychiatry 2012; 58: 596–604. 4 Drapeau A, Marchand A, Beaulieu-
3 Doherty DM, Moran R, Kartalova- Pre´vost D. Epidemiology of
O’Doherty Y. Psychological Distress, psychological distress. In Mental

© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
Caring Science.

Illnesses – Understanding, Prediction and
Control, (LAbate PL ed.), 2012,
InTech, Rijeka, 155–34.
5 Doran DM. Psychological distress as
a nurse-sensitive outcome. In Nurs-
ing Outcomes The State of the Art, 2nd
edn (Doran DM ed.), 2011, Jones &
Bartlett Learning, Sudbury USA.
6 Ridner SH. Psychological distress:
concept analysis. J Adv Nurs 2004;
45: 536–45.
7 Van Oppen P, Smit JH, Van Balkom
AJLM, Zitman F, Nolen WA, Beek-
man AT, Van Dyck R, Penninx BW.
Comorbidity of anxiety and depres-
sion. Eur Psychiat 2007; 22: S333–S.
8 Haftgoli N, Favrat B, Verdon F, Vau-
cher P, Bischoff T, Burnand B, Herzig
L. Patients presenting with somatic
complaints in general practice:
depression, anxiety and somatoform
disorders are frequent and associated
with psychosocial stressors. BMC Fam
Pract 2010; 11: 67.
9 Lowe B, Spitzer RL, Williams JB,
Mussell M, Schellberg D, Kroenke K.
Depression, anxiety and somatization
in primary care: syndrome overlap
and functional impairment. Gen Hosp
Psychiatry 2008; 30: 191–9.
10 Kroenke K, Outcalt S, Krebs E, Bair
MJ, Wu J, Chumbler N, Yu Z. Asso-
ciation between anxiety, health-re-
lated quality of life and functional
impairment in primary care patients
with chronic pain. Gen Hosp Psychia-
try 2013; 35: 359.
11 Kroenke K. Patients presenting with
somatic complaints: epidemiology,
psychiatric co-morbidity and man-
agement. Int J Methods Psychiatr Res
2003; 12: 34–43.
12 Evans DL, Charney DS, Lewis L,
Golden RN, Gorman JM, Krishnan
KR, Nemeroff CB, Bremner JD, Car-
ney RM, Coyne JC, Delong MR, Fra-
sure-Smith N, Glassman AH, Gold
PW, Grant I, Gwyther L, Ironson G,
Johnson RL, Kanner AM, Katon WJ,
Kaufmann PG, Keefe FJ, Ketter T,
Laughren TP, Leserman J, Lyketsos
CG, McDonald WM, McEwen BS,
Miller AH, Musselman D, O’Connor
C, Petitto JM, Pollock BG, Robinson
RG, Roose SP, Rowland J, Sheline Y,
Sheps DS, Simon G, Spiegel D, Stun-
kard A, Sunderland T, Tibbits P Jr,
Valvo WJ. Mood disorders in the
medically ill: scientific review and
© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
Caring Science.
Experiences of Psychological Distress
recommendations. Biol Psychiatry
2005; 1: 175–89.
13 Henningsen P. Medically unex-
plained physical symptoms, anxiety,
and depression: a meta-analytic
review. Psychosom Med 2003; 65:
528–33.
14 Fagring AJ, Kjellgren KI, Rosengren
A, Lissner L, Manhem K, Welin C.
Depression, anxiety, stress, social
interaction and health-related quality
of life in men and women with
unexplained chest pain. BMC Public
Health 2008; 8: 165.
15 Ekstedt M, Fagerberg I. Lived experi-
ences of the time preceding burnout.
J Adv Nurs 2005; 49: 59–67.
16 Jingrot M, Rosberg S. Gradual loss of
homelikeness in exhaustion disorder.
Qual Health Res 2008; 18: 1511–23.
17 Marchand A, Demers A, Durand P.
Do occupation and work conditions
really matter? A longitudinal analysis
of psychological distress experiences
among Canadian workers. Sociol
Health Illn 2005; 27: 602–27.
18 Masse R. Qualitative and quantita-
tive analyses of psychological dis-
tress: methodological comple-
mentarity and ontological incom-
mensurability. Qual Health Res 2000;
10: 411–23.
19 Walters P, Tylee A. Mood disorders
in primary care. Psychiatry 2006; 5:
138–41.
20 World Organization of National Col-
leges, Academies, Academic Associa-
tions of General Practitioners/Family
Physicians, World Health Organiza-
tion. Integrating Mental Health Into
Primary Care: A Global Perspective.
2008, World Health Organization,
Geneva.
21 Menchetti M, Belvederi Murri M,
Bertakis K, Bortolotti B, Berardi D.
Recognition and treatment of depres-
sion in primary care: effect of
patients’ presentation and frequency
of consultation. J Psychosom Res 2009;
66: 335–41.
22 Copty M, Whitford DL. Mental
health in general practice: assess-
ment of current state and future
needs. Ir J Psychol Med 2005; 22: 83–
6.
23 Aguera L, Failde I, Cervilla JA, Diaz-
Fernandez P, Mico JA. Medically
unexplained pain complaints are
associated with underlying
693
unrecognized mood disorders in pri-
mary care. BMC Fam Pract 2010; 11:
17.
24 Greer J, Halgin R, Harvey E. Global
versus specific symptom attributions:
predicting the recognition and treat-
ment of psychological distress in pri-
mary care. J Psychosom Res 2004; 57:
521–7.
25 Hinchey SA, Jackson JL. A cohort
study assessing difficult patient
encounters in a walk-in primary care
clinic, predictors and outcomes. J
Gen Intern Med 2011; 26: 588–94.
26 Horton SM, Poland F, Kale S, Drach-
ler Mde L, de Carvalho Leite JC,
McArthur MA, Champion PD, Pheby
D, Nacul L. Chronic fatigue syn-
drome/myalgic encephalomyelitis
(CFS/ME) in adults: a qualitative
study of perspectives from profes-
sional practice. BMC Fam Pract 2010;
11: 89.
27 Tylee A, Walters P. Underrecognition
of anxiety and mood disorders in pri-
mary care: why does the problem
exist and what can be done? J Clin
Psychiatry 2007; 68(Suppl 2): 27–30.
28 Hahn SR, Kroenke K, Spitzer RL,
Brody D, Williams JB, Linzer M,
deGruy FV. The difficult patient:
prevalence, psychopathology, and
functional impairment. J Gen Intern
Med 1996; 11: 1–8.
29 Lindseth A, Norberg A. A phe-
nomenological hermeneutical
method for researching lived experi-
ence. Scand J Caring Sci 2004; 18:
145–53.
30 Ricœur P. Interpretation Theory:
Discourse and the Surplus of Meaning.
1976, Texas Christian University
Press, Fort Worth, Texas.
31 World MAGA. World Medical Asso-
ciation Declaration of Helsinki: ethi-
cal principles for medical research
involving human subjects. J Int
Bioethique 2004; 15: 124.
32 Rogers C. On Becoming a Person: A
Therapist’s View on Psychotherapy.
1978, Houghton Mifflin, Boston.
33 Gustafsson G, Norberg A, Strandberg
G. Meanings of becoming and being
burnout–phenomenological-
hermeneutic interpretation of female
healthcare personnel’s narratives.
Scand J Caring Sci 2008; 22: 520–8.
34 Arman M, Hammarqvist A-S, Rehns-
feldt A. Burnout as an existential
694 T. Arvidsdotter et al.
deficiency–lived experiences of
burnout sufferers. Scand J Caring Sci
2011; 25: 294–302.
35 Stijn V, Paul V. Professional Burnout
in the Mirror: a qualitative study
from a lacanian perspective. Psy-
choanal Psychol 2005; 22: 285–305.
36 Antonovsky A. Unraveling the Mystery
of Health: How People Manage Stress
and Stay Well, 1987, Jossey-Bass, The
Jossey-Bass social and behavioral
science series, San Francisco, Califor-
nia, 99-0150100-8.
37 Lazarus RS, Folkman S. Stress,
Appraisal, and Coping. 1984, Springer,
New York.
© 2015 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of
38 Fors A, Ekman I, Taft C, Bj€ orke-
lund C, Frid K, Larsson ME, Thorn
J, Ulin K, Wolf A, Swedberg K.
Person-centred care after acute
coronary syndrome, from hospital
to primary care—A randomised
controlled trial. Int J Cardiol 2015;
187: 693–9.
39 Arvidsdotter T, Marklund B, Taft C.
Effects of an integrative treatment,
therapeutic acupuncture and con-
ventional treatment in alleviating
psychological distress in primary care
patients - a pragmatic randomized
controlled trial. BMC Complement
Altern Med 2013; 13: 308.
40 Arvidsdotter T, Marklund B, Taft C.
Six-month effects of integrative
treatment, therapeutic acupuncture
and conventional treatment in allevi-
ating psychological distress in pri-
mary care patients–follow up from
an open, pragmatic randomized con-
trolled trial. BMC Complement Altern
Med 2014; 14: 210.
41 Arvidsdotter T, Marklund B, Taft C,
Kyl
en S. Quality of life, sense of
coherence and experiences with three
different treatments in patients with
psychological distress in primary care:
a mixed-methods study. BMC Comple-
ment Altern Med 2015; 15: 132.
Caring Science.