Transcript Psychological Factors in ill-Health

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Psychological Factors
in Ill-Health
Dr. Craig Jackson
Senior Lecturer in Health Psychology
Faculty of Health
BCU
www.health.bcu.ac.uk/craigjackson
Gabriel T Byrne
Linking Emotions with Physical Symptoms
“The good physician treats the disease, but
the great physician treats the person.”
William Osler
Non-Specific Symptoms
Often missed in assessment
Dualism
“If you are distressed by anything external, the pain is not due to the thing
itself, but to your estimate of it; this you have the power to revoke at any
moment”
Marcus Aurelius 180BC
Dualism
Mind / Body Divide
Rene Descartes'
Biopsychosocial Unification popular in last 10-15 years
Traditional model of Disease Development
Pathogen
Modifiers
Lifestyle
Individual susceptibility
Disease (pathology)
Dominance of the biopsychosocial model
Mainstream in last 15 years
Hazard
Illness (well-being)
Psychosocial Factors
Attitudes
Behaviour
Quality of Life
Rise of the worker as
a “psychological
entity”
Mental States & Physical Well-being
“Triggering” Hypothesis
Chinese # 4
Phillips et al. 2001
World cup 1998
Carroll et al. 2002
Stressful Events and Breast Cancer
Chen et al. 1995
Scottish Heart Attack Deaths
Evans et al. 2002
The “Baskerville” Effect
Is disease real or is it in the mind?
Physiological Response to Stress
Chronic stress & Acute stress
Pituitary Gland, Hypothalamus and Amygdala
Adrenal glands =
Secrete hormones
Epinephrine
Cortisol
Heart
Arteries
Stomach
Lungs
Muscles
=
=
=
=
=
Glucocorticoids
beats faster
widen
digestion stops
faster / shallow
tense
Damage from Stress
Arterial damage
Increased glucocorticosteroids weaken immune system
reduce bone mass
reproductive suppression
memory problems
Anxiety
Depression
Tension
Sleeping problems
Apathy
Apprehension Alienation
Resentment
Confidence
Aggression
Withdrawal
Restlessness
Indecision
Worry
Concentration
Tired
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
Common Misconceptions about Health
“I like
money”
“I like
money too”
“Exploit someone new today”
Allergies – the role of psychology
Allergies
Somatization and Fashionable Diagnoses
Somatoform Disorders (DSM IV 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
Chronic Fatigue Syndrome
1.
2.
3.
4.
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
Which causes which?
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 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
Prevalence of Non-Specific Symptoms
Symptom
Prevalence %
Stuffy nose
Headaches
Tiredness
Cough
Itchy eyes
Sore throat
Skin rash
Wheezing
Respiratory
Nausea
Diarrhoea
Vomiting
Heyworth & McCaul, 2001
46.2
33.0
29.8
25.9
24.7
22.4
12.0
10.1
10.0
9.0
5.7
4.0
Modern day complaints
Multiple Chemical Sensitivity
Chronic Fatigue Syndrome
Sick Building Syndrome
Gulf War Syndrome
Low-level Chemical Exposure
Electrical Sensitivity
Historical complaints
Railway Spine
Neurasthenia
Combat Syndrome
Psychological / Perceptual Process of Illness
Internal Processes
“Do
I notice internal changes?”
“Should

I interpret them negatively?”
“Should I think they are important?”
External processes

“Do I notice external sources?”

“What should I believe about it?”

“What should I do about it?”
MENTAL SCHEMA
Internal representation of the world
(knowledge, attitudes, beliefs)
What do we believe about health?
What do we believe affects health?
Factors Influencing Symptom Development
Selective Internal Attention
Tedious & un-stimulating environment
Little communication
Stressful environment
Learned behaviours
“Negative Affectivity”
OVER FOCUS ON SYMPTOMS
Comparisons
Attributions
Responses
Blame
Pessimism
Factors Influencing Symptom Development
Selective External Attention


Heightened concern about risk
involuntary
uncontrolled
lack of information
dreaded consequences
Mistrust of government / industry
 Attitudes about medicine

Political agenda

Legal agenda

Social and political climate

Media and pressure group activity
OVER FOCUS ON SYMPTOMS
Comparisons
Attributions
Responses
Blame
Pessimism
Personality
Hey.
On way
Hi
Claire.
Are
home. Left
you
around
lecture
earlyand
do
cosyou
feelfancy
like a
crap. Next time!
brew?
A good sign or a bad sign?
Personality type
Optimism vs Pessimism
Negative Affectivity
Hardiness
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
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
Bias – The placebo effect really does work!
Most effective medication known!
In approx. 30% of pop.
Subjected to more clinical trials than any other medicament
Nearly always does better than anticipated
The range of susceptible conditions seems limitless
Does not always occur
Present in subjective and objective outcomes
Negative outcomes can occur (Nocebo effect)
•Big pills better than smaller pills
•Red pills better than blue
Patient’s “knowledge” of their treatment causes bias
•4 pills better than 2
e.g. Benedetti & the Turin study
•30% of pop.
•Sham surgery vs arthroscopy for osteoarthritis
Treatment Bias of Healthcare
A.A. Mason
Congenital Ichthyosis
Hypnosis
Cured severe case of 16yr old male
Mistaken C.I. for Acne Vulgaris
Could not repeat successful treatment
Bennedetti & the Turin Study
Behavioural Responses to Diagnoses
Hedonism
Put life in order
Premature grieving
ADAPTIVE COPING
Talk about it
Planning
Changes
Sick Role
Illness Behaviour
Over-sensitivity to symptoms
Premature death
MALADAPTIVE COPING
Drink
Eat
Substance use
Hierarchy of Needs
Self actualisation (personal growth and fulfilment)
GROWTH
NEEDS
Esteem (self and others)
Belonging (group membership, affection, companionship)
HOMEOSTATIC
NEEDS
Security (safety, stability, continuity)
Bodily needs (food, drink, safety)
Maslow 1954
Four Pathways of Psychological Factors in Ill-Health
1)
Part of Cause of Health Condition
e.g.
Influencing factors (personality)
Risky behaviours
2)
Part of Health Condition
e.g.
Stroke, Metastases
3)
Effects of Health Condition
e.g.
Chronic ill-health
4)
Psychological Interventions
e.g.
Therapeutic benefits
Increased compliance
depression, anxiety, withdrawal
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
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.