A Comprehensive Clinical Model of Suffering

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Figure 1.
The Comprehensive Clinical Model of Suffering.

Table 1.

Matrix of Axes and Domains of Suffering with Clinical Examples

Axis	Domain	Threat or Loss
Biomedical	Symptoms	Comfort	Pain, Nausea Dizziness, Insomnia
Biomedical	Functions	Ability	Mobility, Self-Care, Sleep, Control
Sociocultural	Roles	Performance	Worker, Caregiver, Provider, Protector
Sociocultural	Relationships	Connection	Family, Friend, Colleague, Lover
Psychobehavioral	Emotions	Emotional Distress	Fear, Anger, Sadness, Loneliness, Grief
Psychobehavioral	Thoughts	Psychological Distress	Worries, Regrets, Confusion, Loss, Worthlessness, Hopelessness
Existential	Narrative	Personal Identity Wholeness Meaning	Expectations, Acceptance, Future
Existential	Worldview	Spiritual Distress Value Conflicts Traditions	Conflicts in perceptions, values, guilt

Table A1.

Domains of Suffering in the Patient Vignette

Axis	Domain	Threat or Loss
Biomedical	Symptoms	Night sweats, brain fog, fatigue, joint pain, pruritis, vaginal dryness, decreased libido, weight gain
Biomedical	Functions	Insomnia, not running due to joint pain
Sociocultural	Roles	Hard to perform at work due to brain fog and fatigue
Sociocultural	Relationships	Sexual relationship with partner affected due to decreased libido, fatigue, and dyspareunia
Psychobehavioral	Emotions	Fear, sadness
Psychobehavioral	Thoughts	Anxious thoughts about teenage children and ailing father
Existential	Narrative	Realizing that a significant part of her identity has been defined by her sexuality, attractiveness, and reproduction, she wonders who will she be as she becomes a post-menopausal woman?
Existential	Worldview	Entering a later stage of life, she asks herself: What is her life all about? Where does it fit in the life of her family and the big picture of why she is on the planet?

Table A2.

Exploratory Questions

Axis	Domain	Threat or Loss
Biomedical	Symptoms	Are you suffering? What causes you the most distress/frustration? If we could relieve one thing, what would that be? Do your symptoms upset or embarrass you?
	Functions	What does X keep you from doing? What could you do if X was not so bad? What do you fear you might have to give up? What is it like for you to depend on others?
Sociocultural	Roles	Who else is affected by your X? Who else are you worried about because of your X? In what areas of life are you falling short due to X? What roles have you had to give up?
	Relationships	How has X changed how you relate to others? What is happening at home, work, XYZ? Do you feel you’re letting others down because of X? Is X impacting your marriage? Parenting? Friendships?
Psychobehavioral	Emotions	How does having X make you feel? What are your biggest worries? Are you angry/depressed about X? Do you feel guilty about X?
	Thoughts	What thoughts weigh upon your mind? In your mind, what accounts for X? What concerns you the most about X? What do you imagine as the worst-case scenario?
Existential	Narrative	How do you see this all working out? How has X changed what you expect out of life? How does having X change who you are? What does X mean for you now? In the future?
	Worldview	Do you have any spiritual concerns? What or who do you want to blame for all this? What conflicts have emerged from your experience with X? What is the worst thing about your current situation?