Transcript What should I believe about it?

The Biopsychosocial
Approach
Dr. Craig A. Jackson
Occupational Psychologist
Research Director
Health Research Consultants
ResearchConsultants.co.uk
Gabriel T Byrne
Linking Emotions with Physical Symptoms
“The good physician treats the disease, but
the great physician treats the person.”
William Osler
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
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
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
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
Placebo & Nocebo
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)
Placebo
Big pills better than smaller pills
Red pills better than blue
4 pills better than 2
30% of pop.
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
Is disease real or is it in the mind?