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 Perceptions of Chronic ill Health Prof. Craig A. Jackson Head of Psychology Birmingham City University Patient Pathways start Ill-Health Present to A&E Present to GP end Advise end Investigation end Treatment end Management Treatment Time between start #1 and end #1 ? 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 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 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” 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 Dysautonomia Irritable Bowel Syndrome 1. 2. 3. 4. Multiple Chemical Sensitivity Reactive Hypoglycemia 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 Somatization and Fashionable Diagnoses 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 “Chronic Multi-Form Somatic Symptoms” 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? Malingering Malingering 0 to 10% of consultations according to practice / specialty Secondary gain is external Custom and practice in some workplaces Entitlement 4 criteria – (i) intentional, (ii) false, exaggerated or misattributed complaints, (iii) volitional, (iv) non-trivial consequences Malingering desire to outwit those in authority successful malingerers are likely to repeat behaviour illnesses that rely on subjective symptoms for diagnosis are easiest to simulate doctors are not trained or prepared for patient deception doctors and lawyers may collude either actively or passively against a third party Factitious Disorders (DSM-IV) Dramatic but inconsistent medical history Unclear symptoms that are not controllable and that become more severe or change once treatment has begun Predictable relapses following improvement in the condition Extensive knowledge of hospitals and/or medical terminology, as well the textbook descriptions of illness Presence of many surgical scars Factitious Disorders (DSM-IV) Appearance of new or additional symptoms following negative test results Presence of symptoms only when the patient is alone or not being observed Willingness or eagerness to have medical tests, operations, or other procedures History of seeking treatment at many hospitals, clinics, and doctors offices, possibly even in different cities Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care providers 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 • Depression • Anxiety • History of attention seeking when ill 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 months not working Waddell, 1994 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.