Clinical understanding and clinical implications of response shift.

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.