Transcript Document

The following lecture has been approved for
University Undergraduate Students
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
This lecture may contain
information, ideas, concepts and
discursive anecdotes that may be
thought provoking and challenging
BioPsychSocial Factors
in Ill-Health
Prof. Craig Jackson
Prof of Workplace Health Psychology
Division of Psychology
BCU
www.health.bcu.ac.uk/craigjackson
Mystery Health Problems 1
Mystery Health Problems 2
Mystery Health Problems 3
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 patient 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?
Linking Emotions with Physical Symptoms
Which causes which?
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
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
“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
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
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.
Hi
H. On
Are way
you
home. Left
around
lecture and
earlydo
you
a
cos fancy
feel like
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 :
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
Mind over Matter
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
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, depression, anxiety, withdrawal
4)
Psychological Interventions
e.g.
Therapeutic benefits
Increased compliance
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
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.
21st Century Satanic Mills
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
The benefits of support groups?
The benefits of support groups?