Recent years have seen great interest in the suggestion that between-group aggression and within-group altruism have coevolved. However, these efforts have neglected the possibility that warfare – via its impact on demography – might influence human social behaviours more widely, not just those directly connected to success in war. Moreover, the potential for sex differences in the demography of warfare to translate into sex differences in social behaviour more generally has remained unexplored. Here, we develop a kin-selection model of altruism performed by men and women for the benefit of their groupmates in a population experiencing intergroup conflict. We find that warfare can promote altruistic, helping behaviours as the additional reproductive opportunities winners obtain in defeated groups decrease harmful competition between kin. Furthermore, we find that sex can be a crucial modulator of altruism, with there being a tendency for the sex that competes more intensely with relatives to behave more altruistically and for the sex that competes more intensely with non-relatives in defeated groups to receive more altruism. In addition, there is also a tendency for the less-dispersing sex to both give and receive more altruism. We discuss implications for our understanding of observed sex differences in cooperation in human societies. Media summary: Recent research has suggested that altruism and warfare might have evolved together. However, by focusing only on behaviours that improve success in battle, this work has ignored the potential for warfare to influence altruism more widely – and has also neglected the possible role of sex differences in this context. We developed a mathematical evolutionary model to explore these questions. We found that men, the sex that historically participated in war and also migrated less often, would have tended to be more altruistic and also receive more help from other men – forming ‘boys’ clubs’. Depending on the nature of warfare and migration, other systems are also possible, including societies where it is mainly men who help women or even ‘girls’ clubs’.et al. et al.et al.et al.et al.The last decade has seen considerable multidisciplinary interest in understanding the potential evolutionary links between warfare and the high levels of altruism observed in human societies . Notice that results for reproductive skew could be recovered by substituting Ni with the appropriate number of ‘effective’ equal-fertility breeders, and our results hold in this case (see Supporting Information).At the beginning of the life cycle, the  Feldman  and Mich  ti and the conquering group's sex-i individuals having competitiveness σiti. The competitiveness modifier σi is equal to the fraction of sex-i reproductive opportunities in a conquered group seized by conquering sex-i individuals and thus modulates the additional reproductive opportunities afforded by warfare to individuals from victorious groups. Notice that, while the model allows for defeated individuals to be forcefully relocated to the victorious group by their conquerors, it does not allow them to have reproductive success in these groups.In groups that are not attacked or that are attacked and successfully defend themselves, sex-i individuals compete only with sex-i groupmates and have competitiveness ti of a sex-i individual is modulated by the altruism xi performed by that sex-i individual towards male and female groupmates indiscriminately, by the altruism xi′ the sex-i individual receives from other sex-i individuals, and by the altruism xj′ the sex-i individual receives from sex-j individuals in their group, such that In the first analysis, the intrinsic competitiveness ti of a sex-i individual is modulated by the altruism xii performed by that sex-i individual towards other sex-i individuals, by the altruism xij performed by that sex-i individual towards sex-j individuals, by the altruism xii′ the sex-i individual receives from other sex-i individuals, and by the altruism xji′ the sex-i individual receives from sex-j individuals in their group, such that In the second analysis, the intrinsic competitiveness ci is the marginal cost incurred by the sex-i individual on account of their altruism towards their groupmates; bi is the marginal benefit enjoyed by the recipient of the altruistic act performed by the sex-i individual; rij = (1 – mi)(1 – mj)rx is the genetic relatedness between groupmates of sex i and of sex j ; and αi = 1 – 2aωMi is the extent to which individuals of sex i compete for reproductive opportunities with same-sex groupmates – i.e. ‘locally’ – as opposed to same-sex individuals in other groups – i.e. ‘globally’ .We first investigate which sex is favoured to perform more altruism, focusing on altruistic behaviours that are uniformly beneficial for the group, that is they are not targeted towards a specific sex of groupmates. Examples of such behaviours include staying on guard to alert groupmates about predators or sharing resources equally among all individuals in the group. Analysing the model, we find that natural selection – including both direct and indirect (i.e. kin selection) effects Hamilton  – favourαi is modulated by a quantity Mi = (1 – σi)σi, which describes the extent to which reproductive opportunities in a conquered group are obtained by a mixture of individuals from the winning and the defeated groups . This will result in higher male than female admixture , and thus men will be the more globally competing sex and women the more locally competing sex (αm < αf = 1). If instead women compete and reproduce in defeated groups to some extent, it can be possible for admixture to be female-biased and, consequently, for women to be competing more globally then men.The scale of competition coefficient ci loss of competitiveness for reproductive opportunities; an indirect-fitness benefit (second term) owing to a corresponding relaxation of kin competition in their own sex, as ci reproductive opportunities become available to sex-i individuals who are competing kin with probability αi and who are related to the focal individual by rii; an indirect-fitness benefit (third term) owing to a bi increase in competitiveness for reproductive opportunities for groupmates who, with probability ½, are men related to the focal sex-i individual by rim or, with the same probability ½, are women related to the focal sex-i individual by rif; an indirect-fitness cost (fourth term) owing to a corresponding increase in kin competition, as fewer reproductive opportunities (–bi) are available for male groupmates  who are derived from the same group – and are thus competing kin – with probabilities αm (or αf) and who are related to the focal individual by rim (or rif). Note that condition (1) holds even when individuals gain a direct benefit from performing the behaviour (ci < 0), in which case this constitutes mutual benefit rather than altruism  is that, by increasing their level of altruism towards groupmates, an individual of sex i incurs: a direct-fitness cost (first term) owing to a –αm ≠ 1 and/or αf ≠ 1). This ensures that the inclusive fitness benefit obtained by acting altruistically towards groupmates (third term in condition (1)) is not exactly cancelled by the associated inclusive fitness cost owing to an increase in kin competition (fourth term), as would happen in populations with limited dispersal in the absence of a mechanism decoupling these two effects (Taylor Consideration of condition (1) reveals that the demography of warfare can generate incentives for within-group altruism under broad conditions. Specifically, altruism can be favoured whenever warfare exports at least a fraction of male or female competition for reproductive opportunities from winning groups to defeated groups  from demographic effects on altruism . By analysing potentials for altruism, we can focus on assessing the effects of sex-specific demography on altruism – the aim of the present study – independently of the details of the cost and benefits functions.Furthermore, condition (1) can be rearranged into the form mm < mf), we predict that men will be more altruistic than women (Am > Af), all else being equal. This prediction arises because, since they disperse less, men are more related to groupmates of either sex than are women (rmm > rmf > rff) and thus reap greater benefits from being altruistic. Second, all else being equal, the sex that – as a result of warfare – competes more locally for reproductive opportunities has a higher potential for altruism towards their groupmates than the more globally competing sex (see αm < αf) – then we predict that women will be more altruistic than men (Am < Af), all else being equal. This prediction arises because, as women compete with other related women more often than men, they reap greater benefits by reducing kin competition through altruistic behaviours than men do (second term in condition 1). In addition, we find that, with increasing values of frequency of war (a), levels of potentials for altruism either increase or do not change, but they never decrease .Consideration of the potential for altruism above (equation 2) reveals two key results regarding which sex is favoured to be more altruistic. First, all else being equal, the sex that disperses at a lower rate has a greater potential for altruism than the more dispersing sex see . For exa sex see . For exacij is the marginal cost incurred by the sex-i individual on account of their altruism towards groupmates of sex j and bij is the marginal benefit enjoyed by the sex-j recipient of the altruistic act performed by the sex-i individual.We have delineated the conditions under which men and women can be favoured to act altruistically to the benefit of all individuals in their group. We now consider cases in which altruistic behaviours can be targeted at individuals of exclusively one sex – and ask whether such altruism should be directed towards male or female groupmates. Analysing the model, we find that natural selection – including both direct and indirect (i.e. kin selection) effects Hamilton  – favourcij/bij < Aij, whereAij is the potential for altruism towards the same sex whereas, if i ≠ j, Aij is the potential for altruism towards the opposite sex.Condition (3) can be rearranged into the form mm < mf), we predict that men receive more altruism (Amm < Amf and Afm < Aff), all else being equal. This is because, in this situation, men are more related to groupmates of both sexes than are women  and thus the benefits reaped by actors of both sexes from being altruistic towards men are higher. Second, both sexes have a higher potential for altruism towards members of the sex that competes more globally, all else being equal (see αf > αm), we predict that men will receive more altruism from groupmates of both sexes (Amf < Amm and Aff < Afm). This is because, as men compete more often with non-relatives, the indirect cost of increased kin competition is lower when helping them than when helping women, for both sexes (fourth term in condition 3). Notice how, in this example, men competing more globally and women more locally leads to women helping groupmates more than men, but both sexes biasing their help more towards men than women in their group (Nm ≠ Nf) do not result in sex differences in potential for altruism .Consideration of the potential for altruism immediately above equation  reveals qual see . Consideir group  and 2b. Moreover, we find that the effects of sex biases in dispersal and the scale of competition – the two key modulators of altruism identified above – may reinforce each other or act in different directions, influencing both who helps and who receives help. Where these two forces act in different directions, who helps more and who receives more help may depend on the exact combination of demographic parameter values (see Supporting Information). It is nonetheless possible to identify four broad patterns of sex-specific altruism. If dispersal is strongly female-biased, men are more altruistic and also receive more help than women, independently of sex differences in the scale of competition. The same configuration is obtained with a moderate male bias in dispersal and men competing more globally. Societies with these demographies follow a ‘boys’ club’ or ‘men help men’ system, where altruism is mostly by and for men. Conversely, if dispersal is strongly male-biased, women are more altruistic and also receive more help than men, again independently of sex differences in the scale of competition. The same pattern is obtained with a moderate male bias in dispersal and women being the more globally competing sex. Societies with these demographies follow a ‘girls’ club’ or ‘women help women’ system, where altruism is mainly a female affair. In the other two configurations the sexes of the predominant helper and helped differ. Women are more altruistic than men, but men receive more altruism when dispersal is moderately male-biased or unbiased, and when men compete more globally (‘women help men’ societies). Instead, men are more altruistic than women, but women receive more altruism when dispersal is unbiased or moderately female-biased, and when women compete more globally . On the other hand, the altruist's female groupmates are more likely to compete for reproductive opportunities against unrelated individuals in other social groups. For this reason, the returns in terms of inclusive fitness benefits are higher when helping the sex that competes more globally.Our aim has been to capture how demography modulates sex-specific altruism in populations experiencing warfare. To this end, we have focused on the roles of dispersal and the scale of competition, whilst assuming that both sexes are equally capable of helping, that is they experience the same costs and provide the same benefits to their recipients. However, if the sexes did differ in the costs and benefits of altruism, then this – fairly trivially – would be expected to drive sex differences in their altruistic behaviour. For example, if one sex were less effective in helping – i.e. providing a lower benefit – this would lead to a higher cost-to-benefit ratio and thus a lower level of altruism than for the more effective sex. If instead the two sexes were equally effective in helping, but one incurred lower costs associated with it, this would lead to a lower cost-to-benefit ratio and thus a higher level of altruism than for the sex experiencing more substantial costs. In addition, we have not considered altruism that is targeted at specific individuals on the basis of kin recognition, which is likely to be an important modulator of human social behaviour. Incorporating kin recognition need not affect the overall level of altruism enacted and received by each sex , but would enable investigation of individual-level variation in addition to the between-sex and between-population variation that we have considered in the present analysis.Furthermore, we found that the effects of sex biases in dispersal and competition can reinforce each other or act in opposing directions, resulting in four broad patterns of sex-specific altruism which we term ‘boys’ club’, ‘women help men’, ‘men help women’ and ‘girls’ club’ (summarised in et al.et al.Box 1.Sex-specific dispersal in ancestral humansRecent years have witnessed a heated debate surrounding patterns of sex biased dispersal in ancestral human populations, living a hunter-gatherer lifestyle in the Pleistocene Marlowe, . Here, wet al. (et al. (et al.et al. (Firstly, extant great apes – chimpanzees and bonobos, our closest living relatives, and gorillas – are all characterised by female-biased dispersal (Lawson Handley and Perrin et al.  found ev (et al.  found no (et al.  argue th (et al. . Hunter- (et al. . However. et al.. However.et al.  found moOverall, notwithstanding the great developments in these three research avenues, it is still unclear what pattern of dispersal was followed by our Pleistocene ancestors. It is possible that dispersal was on average female-biased throughout our history, becoming more pronounced with the advent of agriculture. Alternatively, it may have been unbiased during the Pleistocene and became female-biased after the agricultural revolution, in association with patrilocal residence rules.It might be that demographic asymmetries need to persist for very long times – on the order of millions of years – to have an influence on patterns of sex-specific altruism. This would be the case if the traits under consideration were genetically inherited, or if we were considering genetic components contributing to them. In this circumstance, the demographic patterns relevant for our study would be those of ancestral human populations. Sex-biased dispersal in ancestral humans has been greatly debated in recent years see . If, as qualitative predictions as to sex differences in altruistic behaviours would still be relevant if the traits under question were cultural variants selected on the basis of their effects on the biological fitness of their carrier (‘type-1 cultural selection’, Birch et al.et al.et al. On the other hand, it might be that more recent changes in patterns of dispersal – on the order of centuries or millennia – can result in differences in sex-specific altruism between populations. This would be the case if the altruistic traits under investigation were culturally inherited, or if we were considering culturally inherited contributors to such behaviours. Notice that, since our model identifies men's and women's inclusive fitness interests, our et al.et al.In any of these two cases, empirical studies investigating sex differences in cooperation could offer some support for the results of our study. The potential for such differences has been studied extensively employing economic games in the laboratory, with contrasting results: one metanalysis revealed that interactions between men are more cooperative than interactions between women (Balliet et al. et al.et al.et al. (et al.Two studies investigating cooperation in agro-pastoral societies in South-Western China with economic games (Gong .et al.  showed t. et al., which m. et al.. To our et al. (et al.et al. (Moreover, Gong et al.  found thet al. , but the. et al., might r.et al.  found th


Human vision, thought, and planning involve parsing and representing objects and scenes using structured representations based on part-whole hierarchies. Computer vision and machine learning researchers have recently sought to emulate this capability using neural networks, but a generative model formulation has been lacking. Generative models that leverage compositionality, recursion, and part-whole hierarchies are thought to underlie human concept learning and the ability to construct and represent flexible mental concepts. We introduce Recursive Neural Programs (RNPs), a neural generative model that addresses the part-whole hierarchy learning problem by modeling images as hierarchical trees of probabilistic sensory-motor programs. These programs recursively reuse learned sensory-motor primitives to model an image within different spatial reference frames, enabling hierarchical composition of objects from parts and implementing a grammar for images. We show that RNPs can learn part-whole hierarchies for a variety of image datasets, allowing rich compositionality and intuitive parts-based explanations of objects. Our model also suggests a cognitive framework for understanding how human brains can potentially learn and represent concepts in terms of recursively defined primitives and their relations with each other. A crucial aspect of intelligent, symbolic behavior is the ability to recursively compose known elements into unseen objects and representations, enabling imagination, language, and other creative abilities. A primary limitation of modern deep learning models is the lack of such explicit compositionality, which also makes their learned representations very difficult to interpret. We introduce a novel model architecture that learns to represent images as recursive transformations of differentiable “programs,” allowing interpretable and intuitive generation of images through a process resembling a visual grammar.Human visual cognition exploits hierarchical relationships between objects and their parts. For example, a human face can be modeled as a hierarchical tree of parts, each part’s relative position specified within a local reference frame: eyes, nose, mouth, etc. positioned within the face’s reference frame, the parts of an eye  positioned within the eye’s reference frame, and so on. To emulate such a capability, a computer vision system needs to not only learn what a part looks like  but also the relative transformations of the parts within a local reference frame, and do this recursively in order to compose a human face (or a Picasso painting).Beyond vision, nested structure and hierarchical parts-based decompositions are ubiquitous in human attributes such as natural language  and complex behaviors (such as cooking a recipe or driving to work). For example, driving to work consists of “high-level” behaviors , which are in turn composed of “lower-level” behaviors such as “walk to the house door,” “open the door,” etc. which are in turn composed of other actions: “put left foot in front of the right,” “grasp door handle,” and so on. Recursive modeling confers the important property of compositionality : the samHere, we introduce recursive neural programs (RNPs), which address these problems using a generative model for fully differentiable, recursive tree representations of objects and their parts. Our model relies on hypernetworks , which aThe architecture of our model departs from conventional neural networks in that it generates sequences in a recursive and hierarchical fashion. A latent state at one level of our model generates a sequence of states at the level below, with each lower-level state itself representing a sequence. For example, in representing a human face, a latent state can correspond to an entire face, its sub-states could correspond to features , and their sub-states in turn can correspond to lines, curves, and other primitives that are composed to form these features. Each state consists of two attributes: a sequence of lower-level states , and a sequence of “actions” which correspond to transformations of these states (e.g. rotating or translating a line or a nose on an image “canvas”). We call a function that generates state sequences a state transition function and the corresponding action generating function a “policy.” In our model, each state generates both a transition function and a policy, and therefore represents a “program” for generating states and actions. In a hierarchical, recursive setting, such programs allow for abstraction: for example, a program for drawing a nose does not need to “know” about the placement of the nose or a whole face, only the subparts that will result in a nose.The separation between states and actions is characteristic of recent conceptual models of vision and action , 25, 26.To illustrate our approach, we describe a 3-level RNP, though the recursive nature of the architecture can easily be generalized to more levels . Considece frame . The lowThe “neural program” at each level is implemented by two mutually interacting recurrent neural networks, one implementing a state transition function (or “forward model” for the state) that predicts the next state tk) Fig. . In thistk) Fig. ). The sttk) Fig. . At eachWe use hypernetworks  to proviNote that both the state We first demonstrate how our RNPs can learn to recursively parse images of handwritten digits from the MNIST dataset , charactFinally, we demonstrate the expressive power of our model by generating new images with a “grammar” based on recursive transformations  l layers , and thrPrevious approaches to compositional representations have relied on powerful formalisms such as probabilistic programs  but a noTo test whether this “neural program” embedding space is smooth enough to allow interpolation for novel programs to be generated, we investigated the regions between learned Compositionality is the ability to compose a large (possibly infinite) number of objects using a finite set of compositional elements. The RNP model was designed with compositionality as an important goal. We have already demonstrated how the model can sample program space in regions outside those representing the trained data to generate new objects and compositional elements by interpolating between clusters of rts Fig. A.We also tested the compositional ability of our model in two transfer learning tasks. Firstly, we trained RNPs on all MNIST classes but one (e.g. 7 or 8), and on the Omniglot training dataset  designedses Fig. B.To further explore generative transfer in the model, we adapted an RNP trained on the ETH-80 dataset to generate colored Fashion-MNIST objects by keeping the We next investigated whether the hierarchical, recursive compositionality used by RNPs confers on them any advantages over traditional noncompositional generative models such as a variational autoencoder (VAE). We trained an RNP with only one or two primitives—a straight line, or a straight line and a curve—and compared the generative performance of such an RNP to a standard convolutional VAE with a similar number of parameters as the RNP and using the same primitive(s) as filters in the final deconvolution layer. We found that RNPs outperform VAEs in terms of mean squared error (MSE) reconstruction loss on MNIST datasets Fig. A.Finally, to illustrate the recursive ability of the model, we trained a four-level RNP  could be combined to generate richer multi-modal neural programs. Alternate neural implementations of RNPs, using, for example, an embedding approach , 45 or gFor our results, we used end-to-end backpropagation to train our multi-level RNP networks. However, following predictive coding , gradienIn this article, we used a deep encoder network that translated an image into the mean and log variance of a top-level state vector ng (APC) , 26, whing (APC)  is to usAlso worth investigating are predictive coding-based alternatives to the variational approach to RNPs used in this article; in a predictive coding implementation of RNPs, predictions from parent nodes would be conveyed to child nodes and prediction errors from child nodes to parent nodes would be used to continually update state and action estimates at all levels , 29, 48.A program at tree depth function ). The tr . As showWe train the model described above by exploiting the end-to-end differentiability of the architecture, minimizing the reconstruction loss between the canvas containing the sum of all transformed parts and the input image where where To allow probabilistic sampling of programs, we can express an RNP as a structured form of variational autoencoder (VAE)  to learn KL(q‖p) .


Data analysis was undertaken following the principles of thematic analysis.Recently, esports have been argued to impact esports players' health, particularly for those competing at higher levels. Esports are a relatively new phenomenon, and an inside perspective regarding esports players’ needs and experiences is essential to promote adequate health support for this population. Thus, in this qualitative study, we explored the perspectives of elite esports players and staff members regarding the effects of esports participation on health. Ten semi-structured interviews were performed with members of the Portuguese FIFA , factors of esports that impact mental (2) and mental health (3), and strategies to improve esports players’ health (4). Esports-related factors such as gaming, competition, and performance were said to impact mental health, while equipment, facilities, and esports-related sitting time affect physical health. To minimise those risks, four main strategies were suggested: optimising and scheduling esports training, improving lifestyle habits with an emphasis on physical health, enhancing facilities and equipment, and improving health support, particularly with a mental health professional.Esports players and staff members are concerned and aware of esports’ mental and physical demands. Understanding what esports players need and perceive about their health, complemented with the view of staff members, and their proposed strategies for health promotion might help define and prioritise healthcare needs, which could help players and the broad esports community.The online version contains supplementary material available at 10.1186/s40798-023-00617-0. Esports have been seen to affect esports players' mental and physical health.Esports players may benefit from playing esports by improving cognitive ability and by its positive effects on mental health when players accomplish good performances.Esports participation may be associated with symptoms of common health problems related to esports competition and low performance, while impacting physical health due to using equipment for long periods or in an incorrect way, besides the associated sitting time.The main strategies suggested to improve esports players' health were optimising esports training and scheduling, improving lifestyle habits, enhancing facilities and equipment, and improving health support.The online version contains supplementary material available at 10.1186/s40798-023-00617-0. The popularity of esports worldwide is noteworthy . CurrentHealth at its fullest is the highest attainable standard for every human . In 1948Recently, different problems affecting the health of esports players have been described, including mental health , 17, 18 Hence, to provide adequate healthcare and protect esports players’ health, it is crucial to listen to the players and staff members involved in esports to understand their beliefs, attitudes, and needs regarding their health and the healthcare support currently given to this population. For that, qualitative research is an adequate approach to generate in-depth insights into beliefs, assumptions, values, or practices and is a valuable tool , 32. RecUltimately, the present study aimed to gain new insights and to understand the perceived needs regarding health and strategies to support esports players, to ultimately help promote adequate care for these participants, advancing the understanding of how esports players from higher competitive levels and staff members working with them perceive about health, the impact of esports participation and the health-care support currently given in esports circles. To do so, we qualitatively investigated the perceptions that esports players and staff have on health, how esports affect their health and potential strategies to improve esports players’ health in the esports context. Doing so, we hope to advance on previous literature that quantitatively and qualitatively has evaluated health-related parameters in esports players, which calls for more research in this area.This qualitative study follows a critical realist perspective approach, which posits that we interact with an actual external world and that this world existed before our language, ideas, and concepts about it , 42. HenWe recruited elite and world-class (adapting ) FIFA esThe present study was conducted in collaboration with the FPF and the FPF electronic Football  department, responsible for the coordination of the National eFootball team training camps and the National eFootball League . Aiming to capture a wide range of perceptions of primary stakeholders in the esports ecosystem , purposiFollowing the lead author’s institutional data protection policy and explaining the study's main goals, the FPF eFootball department provided a list of potential participants for the study. Those who expressed interest in participating gave their contact details to directly arrange the interview with the principal researcher (AMP). Additionally, participants were asked to provide the contact of other further potential participants .® for sample characterisation. This survey included questions related to age, gender, education, occupation, and sports registration status (i.e. registered in a sports federation in any other sports) and esports participation. The study was approved by the Portugal Football School Ethics Committee (CE PFS 01.2021).Based on the provided contacts of potential participants given by the FPF eFootball department, 14 players that participated recently in the Portuguese eFootball national team and all four members of the staff were contacted. Six players and all staff members accepted the invitation, while eight players did not respond after three contact attempts. Yet, the last two players interviewed and included in the present study did not add new information, indicating data saturation . All par® by the first author (AMP) between January 2022 and April 2022. The interviews were scheduled depending on the participants' availability. The interviews followed two flexible interview guides, one for esports players and one for staff members . This interview format allowed the interview guide to be supplemented by follow-up and probing questions according to participants' responses, allowing us to explore new topics raised by participants  the cognitive capacities always ended getting better worked … and explored … and increased.”“David: [players] can benefit very much from this competitive practice, above all by really stimulating the brain, […] the question of reflexes and also the actual knowledge that you have to have.”Besides improving other daily activities, those factors were also considered needed to reach the highest competitive scene.Joaquim: “because at this level, the competition is not going to be physical, it’s mostly going to be mental, it’ll cause us a lot of … a lot of emotions, much anxiety, much stress, much frustration …. real exhaustion.”Different participants suggested that esports competition could predispose or exacerbate pre-existing symptoms of mental health problems (i.e. anxiety and sleep problems) and promote addiction  and mental fatigue.“Players can feel a bit addicted to the competition, to the playing of the game and not knowing when to stop, how to stop, how to take a break.”David also added that: the playing of esports always leaves me very tired […], many hours and when we have to be very concentrated and very focused, and this ends up leaving us with this feeling of tiredness despite not having done any actual sport”.Moreover, esports competitions were considered a "strenuous mental activity (Carlos)" where players feel exhausted after competition moments, even when competing for relatively short periods, as exemplified by José: “ when things are going well, when the season is going well, is a good one, when all the work is going well, it very positively affects your mental health”.All participants acknowledged the mental health impact of performance, which is weighted on competition results. Therefore, when players accomplished their performance goals, they improved their sense of achievement, felt happier, and felt more confident with better self-esteem, which was repeatedly stated to improve mental health, as noted by Júlio: “José: whatever the performance that you want to have, may even end up leaving us sad, anguished, frustrated), performance anxiety  and excessive gaming .Conversely, bad results were explained to unveil or promote mental health problems, frequently described as “sadness”, “frustration”, “despair”, “isolation”, and even “depression”  could hinder performance by interfering with cognitive ability and attention to gameplay, ultimately creating a vicious circle of thinking and behaviour . Carlos explained that as “The other major theme derived from the interviews was physical health. All participants associated esports with physical health problems, primarily due to equipment and facilities used while playing and related sitting time.Joaquim: I already feel some pain or other, when it’s an exhausting day of competition … I get to the end and already feel something”) and long term .Gaming equipment  and the facilities where competition and training generally occur  were discussed to affect physical health in the short  that were highlighted to contribute to back pain and poor body posture. Two players reported they had already felt discomfort and stiffness while playing.Júlio: “In terms of future health problems, it’s the … for me, it’s the … knees and knee and posture problems. […] If your posture is not correct, …, backpains […] problems with your bones, in your fingers due to being always making movements and I don’t know … the tension.”Repeated movements and inappropriate gaming equipment, mostly in stiff positions, contributed to musculoskeletal problems, comprising local pain or minor injuries on fingers, hands, back , and knees, which generally did not require medical intervention.César: “The fact of … there being a lot of correlation with videogames being … being kind of sedentary … related to sedentarism. I think that they can bring some of the complications associated with this.”José: “We do not unwind, we spend a lot of time sat down. Obviously, we do not burn the calories that we need to take on and this is going to affect our physical condition negatively.”Increased sitting time related to esports practice was discussed to impact overall health, impairing eating habits and contributing to musculoskeletal problems while also exacerbating existing problems due to prolonged use of the equipment and incorrect postures for long periods.Four main strategies were suggested to improve esports players' health.Joel: “There’s a lot of that idea of “the more hours you put in, the better you’re going to be”, but not always. Perhaps four hours well worked are worth more than eight hours not well worked.”David: “A well-defined timetable, with a well-defined rhythm, almost a well-defined routine so that they are always the best prepared, not only at the level of the state of spirit but also at the physical level, being prepared for the activities.”;Duarte: “They should have, to safeguard against the micro-cycles, more breaks. […] That is, the player is sat down for twenty minutes, there should afterwards be a break of five to ten minutes in compensation. […] A player should pay as much attention to the moments of rest as to the moments of competition.”Having appropriate time management , scheduling pauses between games and training sessions and including periods for other activities were reported as strategies for minimising mental and physical health risks and increasing performance. This has been mostly explained by the member of the esports department:“I switch off completely from video games. I go to the cinema and see a film, I try not to …. I try to really rest my working instrument that is my hands … the players that turn in the best performances are normally the people that are able to distract themselves from this world and have a social life and an active physical life […] I always try and keep myself occupied with various things so that my thoughts are not only focused on this because I think it’s important to have this outlet, this means of escape” having other activities  were examples of activities to refrain from esports, thus optimising esports training. Moreover, to prevent musculoskeletal problems, participants explained that they usually decide to have other activities with no screen or sitting time involved.For that, as exemplified by Jonas: José: “Doing some of the activities that can help me build my self-esteem, good thoughts, relaxation, distracting myself, thinking about various things. […] That’s it, playing sport or going out for a walk […] even when I lose, I go out to train [physically] because whenever I arrive home after this training, I feel very good about myself.”Those strategies were also said to prevent mental health problems related to low performance.Jaime: “Also looking after ourselves, that is, to play some sport. I think that’s also health. Having a balance diet, having time to sleep, at least eight hours or about that, at least in my case.”Carlos: “Those behaviours that we say are healthy or that science believes are correct, to remain capable. […] Avoiding those, avoiding those less good habits both in terms of diet and in terms of sleeping, even smoking and drinking.”Avoid drinking or smoking, having (or aiming to have) a careful diet, improving sleeping time, and being physically active were lifestyle habits mentioned to improve esports players’ health.Carlos: “I think that physical activity helps ...… us to, to unwind. I don’t know what exact word to use but unwind, to improve our energies and release those energies that are … the least good in order to be able to then think more rapidly, eloquently and rationally.”Besides, all participants indicated physical activity as one of the most common habits to promote health, noting the positive impact of physical activity on mental and physical health.José: “I note that when I train [as do exercise], my performance in the game is always better and when I don’t train, some days, I feel that … well, sometimes I have a bit lower level of performance [.] but I really feel this connection and I think that’s why I also believe it’s really important to do sport.”Thus, increasing physical activity was suggested to minimise the mental health consequences of gaming, performance, and competition by being a tool to “clear up their mind”, reduce mental health symptoms, and improve mental capacity (e.g. focus) and overall energy. Since esports was reported as a "mentally demanding activity", performance is believed to be optimised when players regularly do physical activity.Carlos: “Health prevention, I mean…a believe that it’s a important point, besides physical activity.”Regarding physical health, physical activity was argued to avoid and minimise musculoskeletal problems by counteracting the consequences of being in inadequate postures, rigid positions, and doing repetitive movements.It’s more difficult to be fit. […] we spend a lot of time sat downplaying, I think this clearly affects your physical health.”.Also, players highlighted that physical activity is important as an alternative to rest from playing and to balance the health risk they face due to high sitting time related to playing esports. This is illustrated by Júlio when referring “David: “Investment even in equipment that we know is not going to greatly wear out our … our vision or a good chair. […] The monitors should be high technology monitors […] that in their technology have the means of not being so aggressive on the sight.”More appropriate chairs, controllers, and monitors with more advanced technology, developed to minimise risks on both vision and posture, are preferred to prevent physical health problems.Specifically, to prevent visual problems, different participants added that players should respect the distance between the chair and the monitor.David: “In the preventive sense, even before there are any problems, knowing that they [esports players] are at a higher level and that there is some risk, already preparing themselves and being aware and having support for those earlier signs […] safeguarding against future problems if there is intervention new, immediately, to be able to offset the dangers that may come from these areas.”David: “Making recourse to a specialist […], somebody who is able to accompany us and so if we are not able to understand something that is our problem, or the capacity to perceive what is taking place there, then, it’s always about recourse to a specialist on the subject able to help us.”Having access to clinical support, comprising of mental health professionals (e.g. psychologist), medical doctors , nutritionists, exercise professionals , and physical technicians (e.g. physiotherapist), were explained to help prevent or mitigate health consequences of esports practice.Joaquim: “I think that psychological support is very important […] I think it’s so important having a person only focused on this, on everything …. everything that the game requires so that, perhaps, we have … for what the life demands … and then everything mixed”All participants expressed the need for esports teams to have access to a mental health professional regularly to prevent and recognise mental health problems or to help players manage them.César: “At the psychological level, I think it makes sense to have somebody accompanying the players more frequently, that might be able to have more impact […] in competitive environments, having somebody there able to check the mental health of players and be able to better understanding … some of the indications of mental health may bring added advantages.”Moreover, since esports have been reported to demand high mental activity, it was added that psychologists could provide players with strategies to properly cope with the strains of esports competitions to improve performance. In fact, during the interviews, it was consensual regarding the crucial role of a mental health professional  for prevention, treatment, and performance improvement, being proposed that they could act during daily practice and competitions while working with other support staff to help players.Joaquim: “We end up having our coach who give us, perhaps, this mental support, who also kind of has this function as well and more than at the tactical and technical level.”Still, given the lack of structural mental support within esports teams  or access to qualified personnel, esports players explained that they usually rely on their families, friends, coaches, and team players for mental support during and after competitions and during periods of increased stress related to esports.This has been reiterated by coaches, noting their role in supporting esports players during training and, especially, during competition. Moreover, coaches and staff members exemplified their role to foment team cohesion.Joel: “The advantage of esports means you end up having, if you have a team, you always have somebody. So, you’re in this but you’re not in this alone. […] And we do end up creating a family of some type.”Indeed, it was noted that esports is important for socialisation and social life, this being another positive health impact of esports participation to support players’ mental health.José: “Now, thinking about the nutritionist… what we should and should not eat, but also the calories that we are consuming, what is it that has more and what has less, what are the options that might be able to help us, for example, in levels of concentration…”Besides, mental health support access to a nutritionist in an esports team could be a tool to educate players on better nutritional habits on what to eat or avoid improving performance and well-being while training and competing .Júlio: “Perhaps, perhaps it’s that… so if I begin getting pains in my fingers and hands. having a doctor who understands this. who makes x-rays or anything else that may help … . for the pains to go away.”Most players and staff acknowledged that elite esports players could benefit from having access within their clubs to a medical doctor that evaluated physical problems and a physiotherapist or osteopath to prevent or treat musculoskeletal pain and injuries.Duarte: “having this support and already foreseeing the existence of such situations. people know that there are potential dangers, potential injuries that can come from the exhaustive utilisation involved in these competitions, of practising and playing this sport, perhaps then it would be possible in many cases to delay or prevent something that may end up happening as a direct consequence of this sport.”To prevent any major health problems, it was proposed by different participants that esports players should be given access to a health screening with a general clinical history and cardiovascular, musculoskeletal, and ophthalmologic health, like the sport’s pre-participation examination.David: “Sharing, almost constantly sharing these facts so that we are able to gather and increase knowledge about the sport, about what it needs. Connecting this to the particular performance of the clubs, of the players and increasingly involving more specialists, in diverse areas so that they can help in applying more healthcare to virtual football.”Finally, supporting scientific research related to the health consequences of esports is needed so more efficient strategies can be employed, this being one of the topics highlighted by staff members  and one player (i.e. José).César: “It’s trying to seek a parallelism for something that is very similar or another very similar activity and I think that’s the starting point.”One suggestion was to learn from what has been studied and found in workers facing similar occupational constraints  and replicate it to improve health prevention and care for esports players, thus improving how health support is given.Likewise, the findings should be widely shared, so those involved with esports can be aware of the health risks of esports, how health can impact esports performance, and what they might need to improve both health and performance.Health at its fullest is the highest attainable standard for every human . Some paThe importance placed on factors affecting esports players’ health has been recently acknowledged, mostly by qualitative research. Workers and athletes from traditional sports have also discussed physical and mental health problems and share similarities with esports players. For instance, the European Agency for Safety and Health at Work  recognisRecent studies on esports found similar conclusions about the mental health impact of gaming, competition, and performance , 59. As Still, as seen in traditional sports –62, factFurthermore, as studied for traditional sports, the risk of mental health symptoms in elite athletes is related to physical health problems, decreased performance, or maladaptive perfectionism , so an eThe most identified themes regarding physical problems were visual and musculoskeletal problems, in line with previous studies , 63, 64.As for musculoskeletal problems reported, as also noted with increased esports practice and longer careers, it is expected that problems such as overuse or overtraining injuries might arise –21, 63, Different strategies to deal with factors affecting esports players' health were suggested during the interviews. Contrary to anecdotal beliefs and previous reports, elite esports players do not need to spend most of their day playing to excel in their practice , 71. VarAdditionally, as explained, esports players should improve their lifestyle habits to promote and prevent health problems. Players recognised that physical activity, nutrition, sleep, and fitness could benefit esports performance , 34, 70.To avoid other physical health problems, esports players should rely on up-to-date technology, like high technological screen devices and more ergonomic consoles and chairs. Learning from strategies proposed for work-related health problems, possible interventions that should be taken within esports teams could include equipment adaption to esports framework (e.g. ergonomic redesign), and physical activity promotion, besides adjustment of training schedules . LikewisEven acknowledging the need for health prevention and on-time care, a structured esports medical team is not a common reality for most elite esports players , includiFollowing the arising themes linked to esports health, interventions targeting esports players' mental and physical health  are needed to improve and protect esports players' health.First, since many of the current strategies are self-organised, stakeholders engaged with esports  have a key role in promoting the health literacy of esports players, ultimately facilitating esports players' self-efficacy . ImproviFinally, research integrating esports players is needed to promote a more widespread promotion of physical and mental health, and to substantiate the perceived constraints of esports practice for the esports players' health . OuAs previously mentioned, the last two interviewed participants did not add any new information about the esports players' health , thus reaching theme saturation. Although we developed questions, including the follow-up questions, to encourage participants to feel comfortable in the interview, some participants frequently found it challenging to share their experiences which appeared to contribute to the interview duration. We acknowledge that because this is the first qualitative study conducted by AMP, the questioning adopted could be improved. Moreover, the response-driven questions during the interviews could be biased by AMP’s clinical background and her mindset focussed on a health prevention approach.Additionally, during thematic analysis, a distinction between player and staff member responses was not performed. Contrary to our initial beliefs when designing this study, the participants discussed themes regardless of whether players of staff members were comparable, suggesting a consensual perception of the health factors of esports participation and preventive strategies. This could be related with staff members’ experience with gaming and esports, besides their actual role and specific tasks . Still, Lastly, since we only included Portuguese participants associated with eFootball participation, the results discussed here might differ in other esports modalities or national contexts , 89, as Elite and world-class eFootball players and staff members considered that specific esports factors  impact players' mental and physical health. Esports players should optimise their lifestyle habits and training, including logistics while relying on social and clinical support to counteract those factors. Also, it is up to esports teams and those belonging to the whole esports ecosystem   to be awAdditional file 1.Table 1. Interview metrics.Additional file 2. Consolidated criteria for reporting qualitative studies (COREQ).Additional file 3.Supplementary figure 1: Factors and strategies used to improve esports players' health.


Fibromyalgia is a prevalent condition affecting 1–2% of the general population and can result in significant disability. Physicians and patients frequently encounter challenges in managing this condition.The aim of this study was to explore novel management approaches through a qualitative analysis of the doctor-patient relationship.Telephonic interviews were conducted with fibromyalgia patients to investigate their healthcare experiences.Qualitative analysis was performed on patients' narratives using interpretative phenomenological analysis, a methodology that delves into each individual's subjectivity.A total of 19 adult patients with fibromyalgia, primarily middle-aged women , recruited from two university centers in Paris, were included in the study. The narratives of participants revealed substantial suffering and considerable functional impairment, which is paradoxical for a condition often considered benign. They reported an ongoing sense of loss of control, exacerbated by an imbalanced patient-doctor relationship. Patients constantly feared not being heard or believed, and they frequently sought attention from their caregivers. Most participants displayed significant ambivalence toward the nature of their condition and actively sought causal links. Patients' adaptive strategies sometimes worsened their symptoms, as in the case of muscular deconditioning. The healthcare system appeared deficient in managing these patients, characterized by a lack of health professional training, frequent inappropriate responses from healthcare providers, and stigmatization of psychological conditions.Despite its perceived benign nature, fibromyalgia should be regarded as a severe condition due to its substantial long-term consequences. Participants reported a challenging experience with the doctor-patient relationship, marked by a strong sense of dependence and a lack of recognition. The care pathway for these patients appeared unsuitable and disorderly, potentially resulting in iatrogenic consequences. The management of patients with fibromyalgia should be enhanced and directed toward a patient-centered approach. The study provides practical recommendations regarding communication methods and patient care. Somatic symptom disorder (SSD) is a very common condition, affecting 6% of the general population and 17 to 30% of patients consult a general practitioner . The nosAmong these disorders, fibromyalgia is an entity characterized by diffuse musculotendinous pain and excessive emotional burden. Old definitions associated the presence of widespread pain with the finding on physical examination of tenderness in at least 11 of the 18 points of palpation . It affeThis condition often leads to severe disability, deterioration of quality of life, and work stoppage, and results in high healthcare resource utilization and medical nomadism . MoreoveAs caregivers, we felt the need to improve the management of this disease. Several studies have reported qualitative data on the experiences of persons with fibromyalgia, with a global approach, exploring different aspects of this condition –24, but This qualitative study conforms with the COREQ 32 criteria .Qualitative analyses were based on the IPA  method, which aims to understand how people make sense of their major life experiences by adopting an “insider perspective” . IPA is We conducted a reasonably purposive homogeneous sampling of adult persons who had experienced fibromyalgia. The study took place from June 2021 to December 2021 in two centers of the university hospital group APHP Paris Center: the internal medicine department of Georges Pompidou Hospital and the pain management department of Cochin Hospital. Participants with a diagnosis of fibromyalgia established by their referring physician were consecutively included during an outpatient consultation with their referring physician. They were given an information note about the aim and modalities of the study. Oral consent was obtained. They received no remuneration for their participation. The sample size rationale is detailed in Participants were contacted according to their availability and interviewed following a guide . InterviFollowing IPA recommendations, we stopped the patient's recruitment when all researchers agreed that the data were sufficient to ensure an adequate and in-depth understanding of the patient's experience .The verbatim transcripts were analyzed inductively, moving progressively from the descriptive to the interpretative level with consideration of the empirical data.First, the interviews were completely replayed, read, and re-read to get an overall impression. Initial notes were taken with the participants' own words, including several themes, discourse modalities, and the researchers' first interpretations about the participants' intentionality. Special attention was paid to language elements such as rhythm, metaphors, and expressions because these helped to understand the phenomenological level, that is, authentical intentionality.To ensure validity, separate analyses were conducted and then compared by two researchers. Then, in the second stage, themes were determined inductively by searching for recurrences of meanings that made sense to participants while addressing the research questions. Two researchers  triangulated the initial analyses by helping to compare and synthesize emergent and cluster themes.Then, themes were gathered in a third stage named the “matricial stage,” which creates super-ordinate themes addressing the research questions directly for each participant.Each record was analyzed separately in the first instance following this in-depth process. They were then compared with one another, creating the fourth level and ultimately the results.Interpretative features were active at each level of analysis. However, the main researchers tried to limit their effect, as reported in the section on reflexivity . The worThe study was approved by a French IRB (Avis 2019-A030116-51 du Comité de Protection des Personnes Sud Est VI).All patients with fibromyalgia who were offered to participate in the study agreed to do so. A total of 19 participants were included: 84% (16/19) were women, and their mean age was 49.8 years (SD ± 14.6 years). All participants met the DSM-5 SSD criteria and the ACR diagnostic criteria for fibromyalgia . They weParticipants described unbearable symptoms using torture terminology, for example Participant 15  said “I was on an electric chair”. The perceived handicap appeared worthy of advanced chronic illnesses, as expressed by Participant 2 : “I have half a life, half a day” or by Participant 3 : “I feel like a bedridden patient”. A large proportion of participants had experienced work loss, pay cuts, and a reduced social circle. This seemed so important that some participants even expressed the “hope” of having another diagnosis, a more palpable illness that would be acknowledged by medicine and provide the opportunity for treatment, even if it was associated with organ damage. At the same time, they mentioned their good health condition as Participant 3 : “I was happy to know that I had no risk of ending up disabled”.Most participants described a high level of previous functioning and perceived control, lost with fibromyalgia, as reported by Participant 17 : “I was very, very dynamic, I had incredible energy” or by Participant 3 : “I had a lot of energy, I used it up and I have nothing left”. Some participants had fluctuating and unpredictable symptoms that prevented them from planning anything, which led to social and professional withdrawal. In that context, the asymmetric doctor-patient relationship was often mentioned by patients as increasing their loss of control through a feeling of dependence. Consequently, many participants reported a loss of self-esteem and confidence. This condition made the patients feel that they had shifted from being actors to observers.The diagnostic announcement was a key moment that seemed to influence the subsequent clinical course. Most of the participants interviewed seemed to have difficulties accepting it or even just making it their own, as mentioned by Participant 2 : “Making this diagnosis does not help to solve it” or by Participant 18 : “It's unbearable socially speaking, at least people who break their leg can say so”. Most participants also showed ambivalence about accepting it or exploring other avenues, fearing that a differential diagnosis could have been missed. Some patients even felt ashamed of this diagnosis, particularly when a relative had a “more serious” illness, which prevented them from talking about it. This complicated communication and altered their relatives' support. Conversely, a few patients reported good clinical improvement due to the diagnostic announcement, but they were a minority.Almost all the participants expressed a reluctance to receive psychological care. They considered the psychological difficulties related to this diagnosis stigmatizing, as if it questioned the reality of their symptoms, as Participant 12  admitted: “I was told what I did not want to hear”. During narratives, this reluctance manifested as a fluent emphasis on somatic symptoms, while discourse was disrupted when addressing psychological difficulties. Some of them avoided questions about psychological difficulties, interrupting the dialogue when these questions were raised, refusing psychiatric referral, while others agreed to see psychiatrists or psychologists but denied psychological issues, as evoked by Participant 1 : “Yes, I had a psychological shock, actually, I don't feel like that but my wife and my mother…”.Participants described physicians in terms of emotional breakdown and abandonment, attentional and emotional needs, and a fear of being rejected, as Participant 3  said: “I kept saying ‘What a pity he's gone'.”Participants described good attention from the doctor in the initial phase, when the symptoms were attributable to a potentially serious somatic cause, but the quality of listening was perceived as having deteriorated once the doctor understood they were dealing with fibromyalgia. Participants sometimes reported tactless attitudes, e.g., if the doctor made the patient feel that he was wasting his time, as Participant 8  reported: “He told me that I had to stop worrying about life and that because I was a woman, I had a mental burden”.All participants voiced a fear of not being heard and believed by doctors, feeling rejected by them, as mentioned by Participant 9 : “I was the hypochondriac” or by Participant 7 : “You don't have anything, it's nothing, it's in your head”. They expressed a need for reassurance and reported experiencing regression and dependence on doctors. During the research interview, almost all had pressured speech. We interpreted it as a concern for exhaustiveness, making the medical researcher feel that they sought at all costs to be believed, despite the lack of somatic evidence. They used suspenseful effects, trying to convince or impress, e.g., by using very strong images or self-mockery, to make themselves more credible.Participants reported that this conflictual doctor-patient relationship had encouraged them to seek out new practitioners with medical nomadism. Sometimes the doctor's lack of empathy was pointed out as incompetence, indicating that the patient was looking for emotional support.Participants described several consultations where fibromyalgia was misunderstood and its management poorly codified. The mean diagnostic delay exceeded ten years in our sample.Participants expected doctors to acknowledge their doubts instead of maintaining a dogmatic position in this situation of uncertainty, as Participant 12  expressed: “The GP was honest enough to tell me that he did not understand, and I found that very professional of him”. They criticized the restrictive setting of the consultation, not adjusted to their complex problems, as explained by Participant 9 : “we are only allowed to come for one ailment, not more” or by Participant 11 : “You are young, miss, but you know, doctors used to know how to take their time with patients”.The other healthcare workers were also pointed out for their incompetence. Some participants mentioned psychologists who were unfamiliar with this condition, as Participant 12  pointed: “the psychologist I have, we have a good relationship, but at times I feel she is a bit lost”. Others reported attitudes with iatrogenic consequences, such as a physiotherapist telling a patient that she had probably had a stroke, which could increase anxiety. In addition, patients reported frequent situations of accidental mistreatment by healthcare workers, which are not specific to this condition but can contribute to the patient's negative experience.The feeling of not being heard encouraged participants to make multiple attempts to meet “the” doctor who would be able to help them, as Participant 14  said: “I was looking on the internet for specialists who are experts in my symptoms”. The lack of health professional training on this condition was also highlighted by many participants. All these shortcomings seemed to be iatrogenic for them, as their anxiety and malaise increased with the absence of appropriate follow-up.Some responses seemed counterproductive because they ultimately exacerbated symptoms. For example, Participant 7  limited her physical activity to prevent tiredness, yet this seemed to increase global daily fatigue, with possible muscular deconditioning. She explained: “Exercising makes me very tired. I don't want to be even more tired, so I stay on the couch.” Some participants also developed anticipatory anxiety, i.e., watching for the onset of their symptoms, and excessive focus on the slightest sensation. They carried out an excessive number of complementary examinations, and some of them recognized that it increased symptom-related anxiety. Some participants expressed a feeling of fatality and pessimism, limiting coping resources, as reported by Participant 4 : “When I plan something, I call to cancel because I know I will be tired, so I avoid it”.Some strategies aimed to regain control of the situation. In the diagnostic process, many patients conducted their own investigation, practicing significant medical nomadism, as Participant 8  argued: “When you're not well, you look for something, it's a question of survival”. They could refute one doctor's opinion with another's. They sometimes positioned themselves as doctors, appropriating the medical discourse with technical terms and medical explanations, as Participant 12  said: “I had the dose lowered” [of medication]. Some participants were strongly argumentative, using complex reasoning to illustrate their points or even showing aggressiveness to avoid feeling dominated. Several participants also reported a combative attitude with a strong desire to return to their previous state. Thus, some of these strategies for regaining control could have deleterious effects and make the doctor-patient relationship complex because the patient's defensive reaction may be difficult to understand.Being supported appeared to have a major impact, whether by family, friends, or other patients, as expressed by Participant 5 : “I know where to find help”. Other participants found resources in certain traditional or alternative therapies, such as adapted physical activity, as Participant 18  explained: “I was advised to do Chi Gong. It's great, I'd recommend it to anyone, anyone who has a stressful job. Then I did Pilates and stretching, and I felt a bit better”. Some participants managed to combine somatic and psychological approaches; Participant 4  even said that psychological treatment would have saved her some imaging tests: “To do less scanning, I have to do more relaxation”. Despite their reluctance, most participants reported some satisfaction with an intervention at some point by a psychologist or a psychiatrist, as Participant 14  expressed: “She referred me to CBT and it was such a relief”. Finally, several participants described strategies for the acceptance and alleviation of symptoms with “reasonable” goals, which seemed to allow for gradual improvement.We chose the IPA method to explore the relationship between patients with fibromyalgia and the healthcare system because it allows for a deep exploration of the subjectivity of each experience. Analysis of the participants' narratives showed that they experienced major disability, with a feeling of rejection and dependence on the healthcare system. They tried to implement their own solutions with varying degrees of success.This study emphasizes the extent of these patients' suffering and disability caused by an illness often considered benign . This paWe assume that the study interview reproduces the framework of the usual medical consultation, as researchers are doctors. Patients often seemed anxious, emotionally overwhelmed, and had pressured speech. Participants' pressured speech has three possible and not mutually exclusive interpretations: 1) the patient may not want to give voice to the doctor for fear that he will put an end to the interview; 2) it may be a manifestation of anxiety; or 3) a concern for completeness in participants who often seem to have perfectionist traits. For doctors, dealing with these patients is complex, with significant negative countertransference experienced by the researchers during these interviews. They may find it difficult to have an empathetic attitude toward a pressured speech, sometimes emotionally overcharged patient who requires a long consultation. One study showed that anxious physicians who work more than 55 h/week were more likely to find emotionally overwhelmed patients difficult to manage, indicating that sometimes mental availability is lacking in these overworked and stressed physicians .In our study, participants were very reluctant to verbalize their emotions, even though their speech was prolix and filled with somatic problem descriptions. This may be a consequence of alexithymia, as this trait is more common in patients with fibromyalgia and SSD in general , 39. ThePatients are being enrolled in a university hospital environment, which may have favored the recruitment of severe forms and failures in outpatient care. The doctor-patient relationship previously built between the participants and the physicians who recruited them could have influenced their consent to participate. Despite careful precautions to make the participants feel at ease, the researchers' medical status could also have limited the free speech of our participants and the triangulation process, even if we mixed specialties.Of note, the small size of our sample is not a limitation, as IPA does not seek representativeness or data saturation but rather a homogenization of the sample because it is a phenomenological approach that is embodied and contextualized .The analysis of narratives from persons with fibromyalgia emphasized their suffering, their disability, and the perceived lack of recognition from the medical profession, highlighting the need to improve their care and to change the approach of caregivers. Based on issues emerging from the patients' narratives, we provided practical guidelines to help physicians improve their practice , suggestThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.AK, MH, BR, and M-AP contributed to the conception and design of the study. AK and MH interviewed the patients and analyzed them under the supervision of M-AP and BR. AK wrote the first draft of the manuscript. JA, AT, and AC revised the manuscript. All authors fulfill the criteria for authorship, contributed to the manuscript revision, read, and approved the submitted version.


The stimulus, stress, and behavioral and mental response (SSB) model proposes that various stimuli induce stress and behavioral responses, which may, in turn, lead to health problems . In receChildren”. In this Special Issue, 13 papers were published, and we are pleased to find that many high-quality papers appeared in the issue. It is truly a global collection of papers, with authors distributed across many countries, including the United States, France, China, Japan, Israel, and Thailand. These studies cover some key issues related to children’s behavioral and psychological problems, such as “Family integration, regulation and children’s health”, “The mealtime behavior problems of children”, “Parents’ daily hassles and parenting approaches to children’s behavior problems”, “Maternal and paternal authoritarian parenting and adolescents’ impostor feelings”, “Family environment and adolescents’ sexual adaptability”, “The influence of parent’s cardiovascular morbidity on child mental health”, “Resilience among left-behind children”, “Sympathy-empathy and the radicalization of young people”, and “the acute stress symptoms in adolescents during the immediate post-earthquake period”. Numerous studies have identified several risk factors related to behavioral and mental problems of young children, including families’ low socioeconomic status, family dysfunction, physical or psychological abuse, traumatic experiences, and parenting problems ,5,6,7. HThese papers provided a comprehensive understanding of the social and behavioral mechanisms leading to behavioral and mental health problems in children. The information obtained from these studies could be helpful in informing health policy; planning prevention strategies; and designing and implementing appropriate, targeted interventions to help reduce behavioral and mental health problems in children. Many researchers have not only realized these challenges but have also put forward reasonable suggestions for policy and prevention applications. In this Special Issue, Yang and Zhang posit that children with good health render it possible for a family to develop a concerted parent–child relationship, enabling families to function as unified entities (contribution 1). Such a finding calls for policymakers to consider that children’s health has consequences beyond medical and healthcare relevancy. Indeed, the health of children may be intrinsically linked to the function and vitality of familial structures and, by extension, the harmonious coexistence within a society marked by mutual solidarity and cohesion.Acar et al. underscore that interventions focusing on stress management may be effective in reducing daily parenting hassles, which may lead to a decrease in practicing negative parenting strategies and, in turn, lead to a reduction in children’s behavior problems (contribution 2). Efendi and his collaborators revealed striking results in demonstrating the need for the careful evaluation of adolescents, who, despite the absence of tangible physical injuries, may exhibit signs of acute stress disorder (contribution 3). Moreover, the research emphasizes the importance of attentive consideration of the psychiatric complaints from adolescents who are willing to seek mental health assistance.Areas for further efforts: A key issue is that some current studies are not designed from any strong theoretical model, particularly those seeking to elucidate the determinants of people’s behavior. This hinders a deeper understanding of children’s behavior and mental problems, signifying an avenue for scholarly enhancement. To the best of our knowledge, some papers still lack an in-depth and comprehensive overview. In terms of the social and behavioral mechanisms of behavioral and mental problems among children, these particular papers did not delve deep into the core of the matter, which is not very helpful for understanding the real world and solving problems . FurtherOne objective of this issue is to disseminate knowledge of holistic, multidisciplinary approaches to policy application and to assist in the design and implementation of effective intervention programs. It must be mentioned that some research is not very targeted and is not designed according to the need to reduce behavioral and mental health problems in the current literature. Furthermore, few intervention studies aimed at resolving problems have been implemented. Further research is needed to overcome this shortcoming.