Transcript Document
The following lecture has been approved for University Undergraduate Students This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging It is not intended for the content or delivery to cause offence Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation BioPsychoSocial Model The CFS Example Prof Craig Jackson Division of Psychology BCU Traditional model of Disease Development Pathogen Modifiers Class Health Lifestyle Genes Individual susceptibility Disease (pathology) Biopsychosocial model of Illness Hazard Illness (well-being) Psychosocial Factors Attitudes Behaviour Quality of Life Is disease real or is it in the mind? Mystery Health Problems ? Mystery Health Problems ? Mystery Health Problems ? Patient Pathways start Ill-Health Present to A&E Present to GP end Treatment Advise Time between start #1 and end #1 ? end Investigation end Treatment end Management Time between end #1 and start #2 ? Symptoms ? Detection of Chronic Patients Vital due to increased risk of iatrogenic harm Potential chronic patients could be identified by: 1. Size of paper records 2. Attendance records Frequency Regularity Concordance 3. Hospital referral rates 4. Observation by staff Medical Nursing Clerical staff – pattern spotting software Linking Emotions with Physical Symptoms “The good physician treats the disease, but the great physician treats the person.” William Osler Assessment of Chronic Patients Once suspected of CMFSS….. Identify 1 practitioner as the patient’s principle carer Systematic assessment: case notes reviewed patient seen for 1 or more extended consultations Case notes: often extensive useful information within compile a summary of case notes evaluate accuracy of previously listed complaints evaluate accuracy of previous diagnoses include key investigations,personal & family circumstances Appointment: current problems & history explored encouraged to talk about symptoms, associations, concerns and state patient & practitioner to finally agree a problem list Non-Specific Symptoms Often missed in assessment Prevalence of Non-Specific Symptoms Symptom Prevalence % Stuffy nose 46.2 Headaches Tiredness Cough Itchy eyes Sore throat Skin rash Wheezing Respiratory Nausea Diarrhoea Vomiting 33.0 29.8 25.9 24.7 22.4 12.0 10.1 10.0 9.0 5.7 4.0 Heyworth & McCaul, 2001 Modern day complaints Multiple Chemical Sensitivity Chronic Fatigue Syndrome Sick Building Syndrome Gulf War Syndrome Low-level Chemical Exposure Electrical Sensitivity Stress-related ill-health Historical complaints Railway Spine Neurasthenia Combat Syndrome Case Summary of a Chronic Patient #1 Date Symptoms Referral Investigation Outcome 1980 (18) Abdominal pain GP --> surgical OP Appendicectomy Normal 1983 (21) Pregnancy (boyfriend in prison) GP --> obs and gynae OP 1985-7 (23-25) Bloating, abdominal blackouts (divorce) GP --> Gastro and neurology OP 1989 (27) Pelvic pain (wants sterilisation) GP --> obs and gynae Sterilised OP Pain persists for 2 years 1991 (29) Fatigue GP --> infectious diseases unit Diagnosis of ME by patient and self help group 1993 (31) Aching muscles GP --> rheumatology Mild cervical clinic spondylosis 1995 (34) Chest pain, breathless A&E --> chest clinic (child truanting) Termination All tests normal Nothing abnormal IBS diagnosis unexplained syncope Pain clinic - Tryptizol Nothing abnormal Refer to psychiatric services poss hyperventilation Case Summary of a Chronic Patient #2 Date Symptoms Referral 1985 (16) Anorexia Secure unit teenagers 1986 (17) Suicide attempt Secure unit teenagers 1986 (17) Self-harm (A levels) Secure unit CAMHS Psychiatry 1987-9 (18-20) Self-harm. Anorexia (university) UMC 1990 (21) Working as au pair (left university) GP monitoring & anti-depressants 1993 (24) Self-harm (joined commune) Secure unit admission ECT Female. Abused by father from 6 to 15. Moved to boarding school, then to grandparents Insomnia - Feeling worthless – Guilt - Recurrent morbid thought - Bleak views - Self harm – Suicide Ideation Scholastically bright. University. Dropped out. Tried own business. Business failed. Admin working. Case Summary of a Chronic Patient #3 Date Symptoms Referral 1985 (17) Pervasive low mood GP monitors 1986 (18) Suicide attempt Child Psychiatry 1986 (18) Self-harm Psychiatry 1987 (19) Anorexia. Self-harm Psychiatry – CPN 1988 (20) Suicide attempt (failed romance) Psychiatry – CPN 1989 (21) Suicide attempt (failed romance) Psychiatry – CPN 1990 (22) Fertility worries Psychiatry – CPN – fertility counselling 1990 (22) Working in office GP monitoring & anti-depressants 1992 (24) Self-harm MH unit (open door policy) CPN 1996 (26) Chronic Fatigue MH unit (open door policy) CPN 1998 (28) Fibromyalgia MH unit (open door policy) CPN Case Summary of a Depressed Patient ? NO! Date Symptoms Referral Feb 2004 Back Pain GP – referred to physiotherapy Mar 2004 Sciatica? Physiotherapy twice a week Apr 2004 Symptoms continue Sees private Osteopath Apr 2004 Symptoms continue Discontinues Physiotherapy Apr 2004 Symptoms continue Bumps into GP in supermarket – GP refers for MRI May 2004 Symptoms continue MRI scan shows left-side, disc 5 slipped Jun 2004 Referred to orthopaedic surgeon. Surgery required Symptoms continue Female 36 Academic Researcher Unhappy in job Received written warnings about time-keeping and performance Professional Meddling On Psychiatry . . . Winston Churchill “I am sure it would be sensible to restrict as much as possible the work of these gentlemen, who are capable of doing an immense amount of harm with what may very easily degenerate into charlatanry. The tightest hand should be kept over them, and they should not be allowed to quarter themselves in large numbers among Fighting Services at the public expense.“ On psychiatrists, in a letter to John Anderson, Lord President of the Council (December 1942) Common Chronic Ill-Health Complaints • Low Back Pain • Carpal Tunnel Syndrome • Cumulative Trauma Disorders • Tendonytis • Repetitive Strain Injury • Fibromyalgia • Irritable Bowel Syndrome • Chronic Fatigue FORMS OF CHRONIC PAIN & FATIGUE Those with heightened symptoms choose attributions to match concepts of what is currently acceptable in medicine External cause for illness preferred - patient becomes a helpless victim Chronic Patient’s Attributions of Ill-Health • Work • Environment Chemicals Stress Toxins Virus Allergies • Traumatic injury • Anatomy / Ergonomic 21st Century Satanic Mills 21st Century Satanic Mills Somatization and Fashionable Diagnoses Somatoform Disorders (DSM III category) “Somatization disorder” Psychiatric diagnosis Somatization 1. Rationalisation for psychosocial problems 2. Coping mechanism 3. Becomes a way of life Fibromyalgia Multiple Chemical Sensitivity Dysautonomia Reactive Hypoglycemia Irritable Bowel Syndrome 1. 2. 3. 4. Chronic Fatigue Syndrome Vague subjective multisystem complaints Lack of objective lab findings e.g no organic cause Semi-scientific explanations e.g “post-viral syndrome” Symptoms consistent with Depression, Anxiety or general unhappiness Linking Emotions with Physical Symptoms • Patients with physical symptoms arising from psychological distress • Some may not have made the link themselves “Anxiety causes muscle tension. Muscle tension causes headaches” • Don’t rush patient to understand Start from their perspective What do they think is causing physical problems (clues) • Broaden agenda to where problems can be physical and psychological Linking Emotions with Physical Symptoms Which causes which? Modern-Day Patients Patients more involved in their own care than even before The term “consultation” is disappearing Mistrust of Medicine e.g. Shipman, Allit, Meadows cases Less Mysterious and Powerful Change in what is expected from practitioners… …Has changed how practitioners view patients Emphasis on (1) risk reduction (2) public health (3) preventative behaviour “Do you know about statistics?” Some (older patients) still prefer to be told what the treatment will be Skill is in achieving the correct balance for each patient Terminology of Chronic Patients Invokes many emotions in practitioners: despair frustration anger “Heartsinkers” “Difficult” “Fat folders” “Chronic complainers” “G.O.M.E.R” Inadvisable terms Lose faith Offensive Complaints “CMFSS” Irritable Bowel Syndrome Common digestive disorder Functional syndrome Traumatic life events, Personality disorders, Stress, Anxiety, Depression Somatization Not a psychological disorder Night-workers & Loners Psychology important in how symptoms are perceived and reacted to Can poor QoL Become a predictor of who will suffer in advance? Chronic Fatigue Syndrome • Non-specific subjective symptom • Overlap with psychiatric diagnoses (66%) • Chronic long-term inability and tiredness • Both Physical and Psychological fatigue • Most prevalent in white, middle class thirtysomething females • Fatigue dominates activities and life The benefits of support groups? The benefits of support groups? Compensation Neurosis Pending litigation Treatment results often poor Some overt malingering Exaggerated illness due to: suggestion + somatization rationalization + distorted sense of justice victim status + entitlement Adverse legal / admin. systems Harden patient’s convictions With time, care-eliciting behaviour may remain permanent Bellamy, 1997 Compensation Neurosis Improvement in health..... ...may result in loss of status Patient compelled to guard against getting better Financial reward for illness is a powerful nocebo Exacerbates illness In a litigious society, will compensation neurosis become more widespread? Accident Neurosis • Failure to improve with treatment until compensation issue settled • Accident must occur in circumstances with potential for compensation payment • Inverse relationship to severity of injury - Accident neurosis rare in cases of severe injury • Low socio-economic status favors accident neurosis • Complete recovery common following settlement of compensation issue ??? Miller, 1961 Abnormal Illness Behaviour after Compensable Injury Accident neurosis Aftermath neurosis Attitudinal pathosis Compensatory hysteria Compensation neurosis Functional overlay Greenback neurosis Justice neurosis Post accident anxiety syndrome Postaccident fibromyalgia Profit neurosis Railway spine Traumatic hysteria Traumatic neurasthenia Triggered neurosis Vertebral neurosis Whiplash neurosis Accident victim syndrome American disease Barristogenic illness Compensationitis Fright neurosis Greek disease Invalid syndrome Perceptual augmenter Pensionitis Post-traumatic syndrome Psychogenic invalidism Secondary gain neurosis Symptom magnification syndrome Traumatic neurosis Unconscious malingering Wharfie’s back Mendelson, 1984 Secondary Gain Pre-disposition What is the Motivation? • Desire for attention • Punish spouse / others • Solve life’s problems • Cry for help • Diversion from work • Socially approved task avoidance sex with spouse work military duty Secondary Gain Pre-disposition Non-economic motivation? • Loneliness • Difficulty expressing emotional pain • Previous history of attention seeking when ill • Depression • Anxiety Secondary Gain Pre-disposition Who are the Potential Claimants? • Military patients nearing severance • Workers under retirement age • Low job satisfaction • Workers soon to be made redundant • Members of support groups Abnormal Illness Behaviour (Care Eliciting Behaviour) • Disability disproportionate to detectable illness • Constant search for disease validation • Relentless pursuit of “enlightened doctors” • Appeals to doctor’s responsibility • Attitude of personal vulnerability and entitlement to care by others • Avoidance of health roles due to lack of skills and fear of failure • Adoption of sick role due to rewards from family, friends, physicians • Behaviours which sustain the sick role - complaints, demands, threats Blackwell, 1987 Return to Work 10 20 30 40 50 60 70 80 90 100 % returning to work Longer off work = Less likely to return to work <1 2 4 6 8 10 12 14 16 18 20 22 24 Waddell, 1994 months not working Psychological Consequences of Chronic Illness Back Pain • Distress Money worries - Disablement • Reduced Quality of Life • Delay in seeking help Fear Denial • Depressed / Anxious • Increased somatic complaints Pain Fatigue Breathlessness Begins bad habit of seeking help too readily Adjustment Disorder – commonest psychiatric diagnosis Increased risk of suicide in early stages (of some conditions) Behavioural Yellow Flags of Chronic Ill-Health Indicative of long term chronicity and disability Back Pain • Negative attitude – back pain is harmful and disabling • Fear avoidance – stops trying things – disability mindset • Reduced activity • Expects passive treatment to be better than active treatment • Tendency to low morale, depression and social withdrawal • Social / Financial problems Somatization & Sick Role The process by which psychological needs are expressed in physical symptoms: e.g., the expression or conversion into physical symptoms of anxiety, or a wish for material gain associated with a legal action. 1. Auxiliary social support 2. Rationalisation for failure 3. Gratification of nurturance 4. Manipulate interpersonal relations 5. Articulate distress: cry for help 6. Misinterpretation of anxiety / depression symptoms 7. Over-vigilance for significant symptoms 8. Avoids stigma with a physical cause 9. Over-attention reflects learned behaviour 10. Amplification and Negative Affectivity 11. Primary, Secondary and Tertiary gains 12. Unexplained physical symptoms in trauma victims (e.g. abuse) Conclusion • Somatization influenced by numerous factors • Sick role resolves intrapsychic, interpersonal or social problems • Fashionable diagnoses have considerable overlap • Occupational and Environmental syndromes • Non specific and subjective complaints • Underlying depression, anxiety, and history of unexplained complaints • Mass communication + support groups = fashionable way to solve distress • Behavioural aspects of chronic patients – blame, refusal, over-reporting etc. Route of problems? Chemicals Gasses Dusts Particles Light Heat Noise Vibration Stress Radiation Slips, trips, falls Working hours Ergonomics Psych Social or Phys?